F3
SERIAL NUMBER OF PERSON WITHIN THE CENSUS BLOCK:
P1
P2
I
NAME: Stadng with the head of household, enter names of all
persons usually !Ving in the household. If an infant not yet named,
write as Baby .
02. WifeMusband
another schedde mark " X here
r
n
u
PERSON'S COLUMN NUMBER:
1
06. Pmnt of head or spouse
07. Other dative
law 09.Non-rel
Housing Information
(Do not fill for non housing units. For Collective living quarters
fill HI
andtoVacant
H7.)housing units
1. Never mamed
2.Mamed (Registered)
3. Married (Customary)
4. widowed
P7
5. Divorced
6. Legally separated
7. Separated (Not legally)
~.
I
I
5. Burgher
6. Malay
7. m
e
r
P 11
~-
. -
2. Hindu
3. Islam
5.0.Chr.
6.0ther
4. S.L.Moor
88
Another District/Country
DURATION OF RESIDENCE IN THE
ESTATE OF USUAL RESIDENCE:
MC/UC/VILLAGE/
1. Sinhalese 5. Burgher
2. S.L.Tam. 6. Malay
3.LTam.
7.other
4. S.L.Moor
1. Buddhist
2 Hindu
3. Islam
District/country
88
This MC/UC/Village/
Estate
Another MC/UC/ViU/
Estate in this district
1. Sinhalese 5. Burgher
z.S.L.Tam. 6.Malay
3.1.Tam.
í'.other
4. S.L.Moor
1 1 ....................
Another District/Country
,
If vacant write '00'
H4 WHETHER CONVENTIONAL OR
IMPROVISED UNIT
4.R.C.
5.O.Chr.
6.other
77
This MC/UC/Village/
Estate
Another MC/UC/VilU
Estate in this district
....................
p 12
6.0ther
DistridCountry
This MC/UC/ViLlage/
Estate
68 Another MCIUCIVW
;"&,te in this district
2.
1.
m
Another District/Country
H5
A. Walt
D
Disuict/Country
I
1 7 1 ....................
Another District/Country
6.
7.
DiStriC~COuntry
B. Floor
1 7 1....................
- GO To P 14 98 Since birth - GO TO P 14
2.
3.
1.
TIC
2.
3.
4.
5.
-
-
~
Cementblock
Mucl
CadjadPalmyrah
PlanW Mem1 sheet
.............
Other (specify)
6.
5.
C . Roof
Bridc
cabodc
Terrazo/
canent
TieØ Granite
Mud
W d
sand
Other (specify) .............
4.
Estate in this district
Another Districf/covntry
1.
2.
3.
4.
5.
Estate
Estate in this district
Improvisedunit
Conventional unit
PRINCIPAL MATERIALS OF
CONSTRUCTION:
..................................................................................
77
....................
1. Sinhalese 5. Burgher
2. S.L.Tam. 6. Malay
3. LTam.
7. olher
4. S.LMoor
.
1. Sinhalese 5. Burgher
2. S.L.Tam. 6 . Malay
3. I.Tam.
7. other
4. S.L.Moor
98 Since birth - GOTO P 14 98 Shce birth - co TO P 14 98 S h e birth - GO TO P 14 ,98 Since birth
If entire life circle '98 and GO TO P 14
If less than i year write '00'
If vacant write 'o'
H3 NUMBER O F PERSONS USUALLY
LIVING IN THE UNIT:
~~k~
......
77
Districtlcountry
77 This MC/UC/Village/Estate
88 Another MC/UC/Village/Estate in this district
Lf n a , w n k the name of the district or country and its code
4.R.C.
5.O.Chr.
2. Vacant
NUMBER O F HOUSEHOLDS IN THE UNIT.
L
88 SriLanka
?7 Notknown
C
E
m
..................................................................................
Write the name zlld code of the district of birth.
PLACE OF USUAL RESIDENCE:
1.. Buddhist
2. Hindu
3. Islam
I
.....
........................................
PLACE OF BIRTH.
and its code.
..
.....................
1. Sinhalese 5. Burgher
2. S.L.Tam. 6. Malay
3. I.Tam.
7. m e r
ETHNIC G R O U P
1. S i a l e s e
2. SriLankaTamil
3. IndianTamil
4. SriLankaMoor
p 10
I
4. Roman Catholic
5. Other Christian'
6. Other
1. Occupied
E12
88 SriLanka
77 Notknown
II I J Country
I 1. Buddhist 4.R.C.
IRELIGION:
1. Buddhist
2. Hindu
3. Islam
P9
88 SriLanka
77 Not known
If Sri Lanka, circle "88". If not known circle "77, otherwise write
the name and code of the countty.
1-1
I
p8
I
CITIZENSHIP
I
H I OCCUPANCY STATUS:
1. Nevmar. 5. Div.
2. Mar.fleg.) 6. Leg.sep.
3. Mar.(Cus.) 7. Sep
4. Wid.
(Not lega.
6
Asbestos
Concrete
Metalsheet
Cadjad Palmyrahl Straw
n t h p r fcwrifv)
__
P 12
DURATION OF RESIDENCE IN THE MCIUCIVILLAGEV
ESTATE OF USUAL RESIDENCE:
If entire life, circle '98' and GO TO P 14
If less than 1 year write '00'
P 13
P 14
-
88 Another MC/UC/ViUagclEstate hthe district of present
usual residence
If another district or coptry,
write the name of the dlstnct or country and its code
DISABILITY:
spe
y havin seeing difficulties heruin di€fcuitie.s
ing difficulfies, disability in u i p r lim%s, lower h&bs,
epilepcy or any other hysical disab!h mentally retarded
or mentally ill circle fand. fill the dis%lity schedule for
that person, after completmg
- the schedule.
pzp
P 16
P 17
18
M
n
6r
d
6r
P 19
P 20
EDUCATIONAL AITAINMENT
SPEAKING READING AND WRITING ABILITY:
and write" with understanding.
Circle 1 for yes and 2 for no.
S = Sinhala T = Tamil E = English
P 21
IN THE LAST 12 MONTHS A C T M T I E S AND THEIR
DURATIONS B N WEEKS):
A . Employed: That is working for pay, working in own
enterprise, business, profession, working as unpaid family
worker or working as paid apprentice.
B. Unemployed: That is without work and available
:cr work.
C . Engaged in non ecbiumic activity: That is student,
engaged in household work, pensioner. unable to work or child
not attending school etc.
If not engaged in any activity write '00' for that activity.
The sum of all durations should be 52 weeks.
L
O
a
6.
Whelher t w k any action to
find self employment or paid employment in the last 12 months
....................................
Speak
1
,We$
,
4. Employed
m
a
B. Unemployed
. Unemployed
:.Non economic
activity
2
PRINCIPAL NON ECONOMIC ACTIVITY IN THE LAST 12
MONTHS:
If engaged in non economic activity (i.e. P18C z 00) circle
the mam acuvity. If not co TO P 21
2.Household work
3. Income &$at/
Pensioner
4. Unablefloo old to work
5. Child not attending school
6. Other non economic activity
PRINCIPAL OCCUPATION OR KIND OF WORK DONE IN T H E
LAST 1 2 MONTHS:
State clearly exact occupation or kind of work done during
the last 12 months eg. Paddy Cultivator, Tea Plucker, Accounts Clerk, Mathematics Teacher, Vegetable Seller etc.
If the person had more than one occupation/work, the principal occupation/work on which most time was spent.
. Student
. Household
wo*
. InC.
Pensioner
01.
02.
03.
04.
U
1999
M. 1995
08. 1994- 1990
09. 1989- 1985
1998
1984 -190°
2001
2000
10.
....... I Grade. .......
est Exam: ..............
...................................
1.
2.
H9
I
Residential only
Residendal and mmmercid
ROOMS:
1.
2.
Single roomed house
Morethan o n e m
-+
GO
TO H 11
For each of the following.
write the number. If not available write 'O
Numkr
HIO NO. OF ROOMS:
B. unemployed
m
B. Unemployed
B. Unemployed
wnxm
Líving/Dining
Kitchenpantry
2 . Non economic
activity
1. Yes
2. No
Wice m m
1
I
2. No
1. Yes
2. No
Other rooms used for living
H11 AVAILABILITY OF TOILET :
1.
2.
3.
I. Student
4. Unable/
1. Student
4. Unable/
4. Unable/
1. Student
4. unable/
1.Student
4. Unable/
2. Household
tooold
2. Household
too old
tooold
twold
2. Household
too old
1. Household
Work
5. Childnot
Work
5. Childnot
Work
5. Childnot
5. Childnot
5. Childnot
3- h C . rec./
att sch. 3. hC.=C./
a& sch.
att. sch. 3* InC. m-1
att. sch.
att. sch.
3. InC. rec./
e m e r 6. Othernon
Fnsimer 6. Othernon
P s i o n e r 6. Othernon
P s i m e r 6. Othernon
6. Othernon
eco. act.
eco. act.
eco. au.
eco. au.
eco. act.
1.
2.
3.
I
..................................................................................
..................................................................................
nnm
I
..................................................................................
I
5.
Waterseal
Pour flush (Not water seal)
Pit
Bucket
Other (specify) ......................
H l 3 SOURCE OF DRINKING WATER:
2.
1.
Unprotected
Proteaed well
well
within premises
3.
4.
Protected well outside premises
Tubewell
Public tap/Street tap
Tap
- within premises
5.
6.
-
R
Exclusively for the unit
S h a d with another unit
None +
GO TO H I3
H l 2 TYPE OF TOILET:
4.
........................................
Single houst:
Attached house/ Annexe
Flat
Line room/ ROWhouse
Slum/ Shanty
Other(specify).....................
CONSTRUCTION
I
1. Yes
.............
If qot completed but oc~lpiedcircle the
appropriate year when first occupied:
Readandwritt
Il
2j
Activity
..Employed
Other (specify)
Asbestos
H7 Y E A R O F
p e l Sori)
.................................
6.
5.
No
'ear: ...... / Grade: ....... I
Iighest Exam: ..............
Metalsheet
Cadjan/ Palmyrah/Straw
Concrete
4.
WHETHER SEEKING EMPLOYMENT
If did not work at all (i.e. P18A = 00) GO TO P24
P
1 . Yes
I
1 Student
v)
--Another District/Country
2.
Tile
2.
5.
4.
3.
TYPE OF STRL'CTURE;
...................
...................
...................
Other edu. institution
Does not attend
For eachlanguage indicate whether the person can "speak", and "read
P
I 88 Anoh
1.
2.
3.
.S l i d
. University
5 . Doesnotattend
1.
-
I
H6
-q...................
.Pre school (go to next
4. Öther educational institution
58 Another MWC/Viiage'/
Another MCRIC/Viilage'/
Estate in the district of
present usual residence
i . Pre school
2 School
3. Univenity
Write the highest year or grade or examination passed.
If never attended school circle '88'.
If currently studying in year 1 write '00' against year.
If below G.C.B(O/L) write Grade/Year passed.
If G.C.E.(O/L) or equivalent or higher examination write the name
of the examination,
pm
years
INSTITUTION IN THE LAST 30 DAYS:
~
-
a
PLACE OF RESIDENCE IMMEDIATELY BEFORE MOVING T O
PRESENT USUAL RESIDENCE:
If a
P 15
c. Roof
8 Since birth - GO TO P 14
P 22
INDUSTRY, BUSINESS OR SERVICE:
i
Describe the kind of products made or servicesrendered at the ...........................................................................................................................
~
P 23
PaLT
P 24
work place of the principal occupation
Write the name of the work place.
eg. Paddy Cultivation, Garment Factory, Grocery Shop,
Education Department etc.
...........................................................................................................................
8.
9.
..................................................................................
..................................................................................
H14
3.
4.
5.
1 Governmentemployee
4. Employer
2. Sem government
5. Own account worker
anPIOYee
6. Unpaid family worker
3. Private seaor employee
H1S
If none circle '00'
P 26
Write the total number of sons and daughters who live
here, who five somewhere else and who are dead.
TOTAL NUMBER OF LIVING CHILDREN:
~
If none circle '00'
DATE OF BIRTH OF THE LAST LIVE BORN CHILD:
Write the exact year and month of birth.
If the exact year of birth is not known, write the estimated year of
1 birth and write 88 for month.
-
Karsene
Electricity
Siar
Other (specify)
Ncne
......................
PRINCIPAL TYPE OF COOKING FUEL:
2.
1. Firewood
Gas
TOTAL NUMBER O F CHILDREN BORN ALIVE
P 25
PRINCIPAL TYPE OF LIGHTING:
1.
2.
EMPLOYMENT STATUS AND SECTOR:
River, Tank, Streams etc.
Other (specify) ......................
m
Number
O0 No living children
3.
4.
5.
6.
Im
Number
IO0 Noli5ng children
H16
QmqTm
Month
Kerose~le
Electricity
Saw duseaddy husk
Other (specify) ......................
TENURE:
1. Owned by an occupant
2. Rentfree
3. Rent/Lease
4. Encroached
5. Other (specify) ...............
3
END
OF
QUESTIONS
Al ProVince/District
m
1.2
I3
1.4
I. 1
1.5
1.6
A2 Electorate
~
A5 Sector
A4 G.N. Division
A3 D.S. Division
1.
A7 WardNillagefistate
A6 M.C.IU.C./PS
Urban
2. Rural
3. Estate
~
NAME:
0
u
m
COLUMN NO. OF PERSON IN THE
POPULATION SCHEDULE:
~
SEX:
1 Male
DATE O F BIRTH:
If the exact year of birth is not known,
write the estimated year of birth and Write
88 for month and date.
2 Female
m
I
Month
2 Female
1 Male
n
Date
Year
Month
0
m
I
1 Male
I I I I1 I I I I
I II I I I I
I I
I
2 Female
~
I
Year
Month
1 Male
Year
Date
2 Female
Month
A G E A T WHICH ABOVE DISABILITY
OCCURRED:
(C)
CAUSE OF ABOVE DISABILITY :
1.Congenital
I. 8
4. war/”errorkm
5. Other accident
3.Vehicle accident 6. Other (Specify)
2.mess
HEARINWSPEAKING
DIFFICULTIES :
1.Deaf
2.Dumb
3. Speech difficulties
4, Deaf and Dumb
9.None - GO TO 1.9
~
n
A G E A T WHICH ABOVE DISABILITY
OCCURRED:
(C)
CAUSE OF ABOVE D E A B I L I T Y :
1.Congenital
4.War/”emrisrn
2, Illness
5. Other accident
3. Vehicle accident 6.Other (Specify)
(A)
99 not known
98 at birth
................... I
Date
7
Year:........... 1Grade: .......... I
Highest Exam: .......................
Year:........... I Grade: .......... I
Highest Exam: .......................
............................................
1.Tota. bl.
3. Weak vis.
2. One eye bl.
9. None - G o T o 1.8
1.Tota. bl.
3. Weak vis.
2. One eye bl.
9. None - GO TO 1.8
1.Tota. bl.
3.Weak vis.
2. One eye bl.
9. None - GO TO 1.8
98 at birth
98 at birth
98 at birth
99 not known
99 not known
17
1.M
2.Dumb
9.None -
3.Speechdiffi.
4. Deaf & Dumb
GO TO 1.9
1 . M
2. Dumb
9.None -
~
99 not known
~
98 at birth
n
99 not known
~~
3.Speechdifi.
4.Deaf & Dumb
GO TO 1.9
98 at birth
...................
...................
................... I
................... I
~
- -
(B)
Month
y”
y1.Conge.
4.WarKer.
1.Conge.
4. Warner.
1.Conge.
4. Warfler.
1.Conge.
4. Wxfler.
1.Conge.
4. Warfler.
2. Illness
5. Other acc.
2. Illness
5. Other acc.
2.Illness
5.Other acc.
2.Illness
5.Other acc.
2.Illness
5.0ther acc.
3. Vehi. acc. 6.0ther (Specify) 3. Vehi. adc. 6. Other (Speclfy) 3. Vehi. acc. 6.0ther (Specify) 3.Vehi. acc. 6.0ther (Speclfy) 3.Vehi. acc. 6.0ther (Specify)
99 not known
[
I
I
y-
I. 9
1.Tota. bl.
3. Weak vis.
2. One eye bl.
9. None - GO TO 1.8
1.Totally bi. 3. Weak vis.
2. One eye bl.
9. None - GO TO 1.8
98 at birth
99 not known
~
(A)
Year
school ing
Year:........... 1Grade: .......... 1 Year: ........... 1Grade: .......... 1 Year:........... 1 Grade: .......... 1
Ya.
If below G.C.E.(O/L) write Grademear passed. Highest Exam: .......................
Highest Exam: .......................
Highest Exam: .......................
If G.C.E.(O/L) or equivalent or higher exarnina- ...................................
............................................................................................
tion write the name of the examination,
(B)
I
2 Female
I I I II I I I 1
Date
.
SEEING DIFFICULTIES :
c
m
1 Male
Write the highest year or grade or examination
1.Totally blind 3. Weak vision
2. One eye blind 9. None - GO TO ~8
~
m
I I II I I I I
I 1 I II I II I
Date
0
EDUCATIONAL ATTAINMENT:
(A)
m
~~~
CENSUS UNIT NUMBER:
EZer
auended school circle ’88.
If currently studying in year 1 write ‘00’against
1.7
4 8 Census Block Number
1.M
2.Dumb
9.None -
a
98 at birth
3.Speechdifi.
4. Deaf & Dumb
GO TO 1.9
99 not known
1.Deaf
2.Dumb
9.None -
m
98 at birth
3.Speechdifi.
4.Deaf ¿Q Dumb
.
GO TO 1.9
99 not known
1.W
2. Dumb
9.None -
98 at birth
n
3.Speechdifi.
4. Deaf & Dumb
GO TO 1.9
99 not known
yyYears
yl.Conge.
4. WarKer.
4. Warner.
l . Conge.
4. WarFer.
1.Conge.
4. Warfler.
1.Conge.
4. Warfler.
2. Illness
5 . Other acc.
2. Illness
5 .Other acc.
2. Illness
5. Other acc.
5.Other acc.
2. Illness , 5. Other acc.
2. Illness
3. Vehi. acc. &Other (Specify) 3. Vehi. acc. 6. Other (Speclfy) 3. Vehi. acc. 6.0ther (Specify) 3. Vehi. acc. 6. Other (SpecQ) 3. Vehi. acc. 6 .Other (Specify)
l.Conge.
...................
...................
DISABILITY IN HANDS :
limbs
n.--w:*-.
,E
5
limbs
. -.
....
r
...................
1. Absence of upper limb
2. Paralysis of upper limb
3. Absence of both upper
limbs
4. Paralysii ofboth upper
limbs
n;cahilitv of one hand
...................
1. Absence of upper limb
2. Paralysis of upper limb
3. Absence of both upper
limbs
4. Paralysis of both upper
limbs
5. Disability of one hand
................... I
1. Absence of upper limb
2. Paralysis of upper limb
3. Absence of both upper
limbs
4. Paralysis of both upper
limbs
5. Disability of one hand
1.10
1. Loss of lower limb
2. Paralysis of lower limb
DISABILITY IN LEGS :
(A)
3. Loss of one below knee
4. Loss o f both lower limbs
5. Paralysis of both lower
limbs
6. Loss of both below knees
7 . Disability of one leg
8. Disability of both legs
9. None - GO TO 111
1.11
(B)
AGE A T WHICH ABOVE DISABILITY
OCCURRED
(C)
CAUSE OF ABOVE DISABILITY :
(B)
1.12
OTHER PHYSICAL DISABILITY :
AGE A T WHICH ABOVE DISABILITY
OCCURRED
CAUSE OF ABOVE DISABILITY :
1.Congenital
4. Wat/”emrism
5. Other accident
2. Illness
3. Vehicle accident 6. Other (Specify)
(A)
MENTAL DISABILITY :
(B)
AGE A T WHICH ABOVE DISABILITY
OCCURRED
(C)
CAUSE OF ABOVE DISABILITY :
4. War/Terrorism
5. Other accident
3. Vehicle accident 6. Other (SDecifv)
1.Congenital
2.Illness
~~~~
1. Loss of lower limb
2. Paralysis of lower limb
3. Loss of one below knee
4. L o s s of both lower limbs
5. Paralysis of both lower
Iimbs
6 . Loss of both below knees
7. Disability of one leg
8. Disability of both legs
9. None - GO TO 1.11
Loss of lower limb
Paralysis of lower limb
Loss of one below knee
Loss of both lower limbs
5. Paralysis of both lower
limbs
6. Loss of bo& below h e e s
7 . Disability of one leg
8. Disability of both legs
9. None - GO TO 1.11
$8 at birth
99 not known
Y W
1.
2.
3.
4.
I . Conge.
4. WarFer.
1. Conge.
4. Warner.
4. Warner.
1.Conge.
4. WarFer.
l . Conge.
4. Warner.
2. Illness
5. Other acc.
2. Illness
5. Other acc.
2.Illness
5.0ther acc.
5. Other acc.
2.Illness
5. Other acc.
3.Vehi. acc. 6.0ther (Specify) 3. Vehi. acc. 6. Other (Specify) 3.Veh.i. acc. 6.0ther (Specify) 3. Vehi. acc. 6. Other (Speclfy: 3.Vehi. acc. 6.0ther (Specify)
...................
1. Epilepsy
2. Kidney problems
3. Asthma
4. Lungdisease
5. Heartdisease
6. Disorder resulting from
bums
7. other
9. None - GO TO 1.12
98 at birth
99 not known
n
1. Epilepsy
1. Epilepsy
2.
3.
4.
5.
6.
2. Kidney problems
Kidney problems
Asthma
Lung disease
Heartdisease
Disoîder resulting from
bunts
7. other
9. None - GO TO 1.12
m
98 at birth
99 not known
3. Asthma
4. Lungdisease
5. Heartdisease
6 . Disorder resulting from
bums
7. other
9. None - GO TO 1.12
m
98 at birth
99 not known
...................
...................
....................
...................
1. Epilepsy
2 ; Kidney problems
3. Asthma
4. Lungdisease
5. Heartdisease
6. Disorder resulting from
burns
7. mer
9. None - GO TO 1.12
mv
98 at birth
99 not known
1. Epilepsy
2. Kidney problems
3.
4
5.
6.
Asthina
Lungdisease
Heartdisease
Disorder resulting from
bums
7. other
9. None - GO TO 1.12
98 at birth
n
99 not known
years
yy1.Conge.
4. Warner.
1. Conge.
4. Warner.
I. Conge.
4. Warner.
4. WarRer.
l. Conge.
4. Warfler.
2. Illness
5 . Other acc.
2. Illness
5. Other acc.
2. Jllness
5. Other acc.
2. Illness
5.0ther acc.
2. Illness
5. Other acc.
3. Vehi. acc. 6.0ther (Specify: 3. Vehi. acc. 6.Other (Speclfy) 3.Vehi. acc. 6.0ther (Specify) 3.Vehi. acc. 6.Other (Speclfy 3. Vehi. acc. 6.0ther (Specify:
l.Conge.
...................
...................
1. Mentally retarded
2. Mentally ill
9. None - GO TO 1.13
WHETHER LIVING IN AN INSTITUTION:
~
2.Illness
m
98 at birth
99 not known
1. Mentally retarded
1. Mentally retarded
2. Mentally ill
2.Mentally ill
2. Mentally ill
9. None - GO TO 1.13
9. None
9. None 98 at birth
co TO 1.13
a
99 not‘known
m
98 at birth
1. Mentally retarded
99 not known
...................
...................
...................
-
GO TO 1.13
m
98 at birth
99 not known
1. Mentally retarded
2. Mentally ill
9. None - GO TO 1.13
98 at birth
Y=
99 not known
yyy1.Conge. 4. Warner.
4. Warrer.
l.Conge.
4. Warner.
1.Conge.
4. Warner.
l. Conge.
4. Warfler.
2. Illness
5. Other acc.
2. Illness
5. Other acc.
5. Other acc.
2. Illness
5. Other acc.
2. Illness
5. Other acc.
2. Illness
3. Vehi. acc. 6.0ther (Specify, 3. Vehi. acc. 6.0ther (Speclfy) 3. Vehi. acc. 6.0ther (Specify) 3. Vehi. acc. 6 . Other (Speclfy 3. Vehi. acc. 6.0ther (Specify:
y-
1.13
‘
7
1
y-
(C)
1. Loss of lower limb
2. Paralysis of lower limb
3. Loss of one below knee
4. Loss of both lower limbs
5. Paralysis of both lower
limbs
6. Loss of both below knees
7. Disability of one leg
8. Disability of both legs
9. None - GO TO 1.11
l. Conge.
1.Congenital
4.War/lèrmrism
5. Other accident
2. Illness
3. Vehicle accident 6. Other (Specify)
(A)
1. Loss of lowerlimb
2. Paralysis of lower limb
3. Loss of one below knee
4. Loss of both lower limbs
5. Paralysis of both lower
limbs
6. Loss of both below knees
7. Disability of one leg
8. Disability of both legs
9. None - GO TO 1.11
l . Conge.
...................
...................
~-
1 Yes
2 No
1 Yes
2 No
...................
1 Yes
2 No
1 Yes
2 No
1.12
(A)
M E N T A L DISABILITY :
(B)
A G E A T WHICH ABOVE DISABILITY
OCCURRED.
(C)
CAUSE OF ABOVE DISABILITY :
-
~
-
1. Congenital
4. WarRerrorism
2. Illness
5.Other accident
3. Vehicle accident 6. Other (Specify)
WHETHER LIVING IN AN INSTITUTION:
1.14
MEANS OF LIVELIHOOD
1.15
1.16
-
1. Mentally retarded
2. Mentally ill
9. None - co TO 1.13
1. Mentally retarded
2. Mentally ill
9. None - Co TO 113
98 at birth
?8 at birth
38 at birth
n
99 not known
y-
n
99 nocknown
y-
n
99 not known
y-
1. Mentally retarded
2. Mentally ill
9. None - GO TO 1.13
1. Mentally retarded
2. Mentally ill
9. None - GO TO 1.13
98 at birth
98 at birth
[
u
99 not known
n
1. Employment
2. Supported by family or relation
3. Supported by an institution or
organization
4.Begging
5 . Other (Specify)
y-
y-
...................
...................
...................
...................
DESCRIBE W H A T I T IS:
1 Yes
1 Yes
2 No
1 Yes
1. Employment
2. Supported by fam.or rel.
3. Supported by an ins. or org.
4. Begging
5.Other (Speclfy)
1. Employment
2.Supported by fam.or rel.
3. Supported by an ins. or org.
4.Begging
5.0ther (Specrfy)
1-g.. ...........................
Kl..
..........................
11..........................
7..
OCCUPATION:
9
..............................
9 9 Not trained
..............................
..............................
_I
None
..............................
..............................
9
None
1 Yes
2 No
1. Employment
2. Supported by fam.or rel.
3.Supported by an ins. or org.
4.Begging
5.other (Speclfy)
99 Nottrained
If the person has an occupation at
present describe the occupation
2 No
..............................
~
IF TRAINED FOR ANY VOCATION
99 not known
l. Conge.
4.Warfler.
l.Conge. 4. Warner.
l. Conge.
4. WarRer.
l . Conge.
4. WarRer.
l. Conge.
4. Warfler.
2. Illness
5. Other acc.
2. Illness
5.Other acc.
5. Other acc.
2. Illness
2. Illness
5.Other acc.
2. Illness
5.Other acc.
3. Vehi. acc. 6.0ther (Specify: 3.Vehi. acc. 6. Other (Speclfy) 3.Vehi. acc. 6.0ther (Specify) 3. Vehi. acc. 6. Other (Speclfy) 3.Vehi. acc. 6.0ther (Specify]
~
1.13
-
1. Mentally retarded
2. Mentally ill
9. None - co To 1.13
..............................
9Y Not trained
I
1 Yes
2 No
1. Employment
2. Supported by fam.or rel.
3. Supported by an ins. or org.
4. Begging
5.mer (Speclfy)
1. Employment
2.Supported by fam.or rel.
3.Supported by an ins. or org.
4.Begging
5.other (Specify)
~N~h""..".................
m-1............................
..............................
t
aind
..............................
9 9 Nottrained
I
g
,
..............................
..............................
2 No
..............................
..............................
..............................
..............................
9
None