Form 6 Family Disability--Line 6

Attachment 3e Family Disability (3 minutes)
Page 1 of 2

DRAFT 2010 NHIS Questionnaire - Family
Family Disability: Version 2
Document Version Date:
Question ID:

FDB.020_00.000 Instrument Variable Name:

QuestionText:

05-May-09

P2DFHEAR

QuestionnaireFileName:

Family

With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions that
cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones I asked
earlier.
[fill 1: Are you/Is ALIAS] deaf or [fill 2: do you/does ALIAS] have serious difficulty hearing?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All persons age 1 or older and random number generator=2

SkipInstructions:

<1,2,D,R> goto P2DFSEE

Question ID:

FDB.040_00.000 Instrument Variable Name:

QuestionText:

P2DFSEE

QuestionnaireFileName:

[fill 1: Are you/Is ALIAS] blind or [fill 2: do you/does ALIAS] have serious difficulty seeing even when wearing glasses?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All persons age 1 or older

SkipInstructions:

<1,2,D,R> if no more persons age 5 or older, goto end of section; else goto P2DFCON

Question ID:

Family

FDB.060_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DFCON

QuestionnaireFileName:

Family

Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have serious difficulty concentrating,
remembering, or making decisions?
Yes
No
Refused
Don't know

UniverseText:

All persons 5 or older

SkipInstructions:

<1,2,D,R> goto P2DFWALK

Page 2 of 2

DRAFT 2010 NHIS Questionnaire - Family
Family Disability: Version 2
Document Version Date:
Question ID:

FDB.080_00.000 Instrument Variable Name:

QuestionText:

P2DFWALK

QuestionnaireFileName:

Yes
No
Refused
Don't know

2
7
9
UniverseText:

All persons 5 or older

SkipInstructions:

<1,2,D,R> goto P2DFDRES

FDB.100_00.000 Instrument Variable Name:

QuestionText:

P2DFDRES

QuestionnaireFileName:

Family

[fill 1: Do you/Does ALIAS] have difficulty dressing or bathing?

1

Yes
No
Refused
Don' know

2
7
9
UniverseText:

All persons 5 or older

SkipInstructions:

<1,2,D,R> if no more persons age 15 or older, goto end of section; else goto P2DFERR

Question ID:

Family

[fill 1: Do you/Does ALIAS] have serious difficulty walking or climbing stairs?

1

Question ID:

05-May-09

FDB.120_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DFERR

QuestionnaireFileName:

Family

Because of a physical, mental, or emotional condition, [fill 1: do you/does ALIAS] have difficulty doing errands alone
such as visiting a doctor's office or shopping?
Yes
No
Refused
Don't know

UniverseText:

All persons 15 or older

SkipInstructions:

<1,2,D,R> if no more persons age 1 or older, goto end of section; else return to P2DFHEAR for next person age 1
or older