16. Does this person have any of the following long-lasting conditions: a. Blindness, deafness, or a severe vision or hearing impairment? -Yes -No b. A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying? -Yes -No
17. Because of a physical, mental, or emotional condition lasting 6 months or more, does this person have any difficulty in doing any of the following activities: a. Learning, remembering, or concentrating? -Yes -No b. Dressing, bathing, or getting around inside the home? -Yes -No c. (Answer if this person is 16 YEARS OLD OR OVER.) Going outside the home alone to shop or visit a doctor's office? -Yes -No d. (Answer if this person is 16 YEARS OLD OR OVER.) Working at a job or business? -Yes -No
|