**APPENDIX 3**

**SELF-REPORT COGNITIVE QUESTIONNAIRE IN FILIPINO**

**National Statistics Office**

**Philippines**

**WASHINGTON GROUP ON DISABILITY STATISTICS**

**Cognitive Testing**

**SECTION 1. Face Sheet**

***Instructions to the respondent:***

Thank you for agreeing to participate in this interview. The purpose of
this project is to develop questions about people's health and abilities
to do certain activities that will eventually be asked of many people of
all ages around the world. For this project, we need to find out if the
questions make sense to everyone and if everyone understands the
questions in the same way. Your interview will help us find out how the
questions are working.

This interview will last about one hour and will primarily be about your
abilities to do certain activities. Many of these questions will seem
repetitive and even somewhat strange or personal. This is because we are
testing the questions, and we need to understand what people are
considering when they form an answer. Please do you best to answer the
questions as you understand them.

Everything that you tell me is confidential and will be kept private. If
you do not want to answer a question, please tell me and I will move to
the next question. Before we begin, do you have any questions?

+-----+--------------------------+---+----------------------------------+
| #   | GEOGRAPHIC               |   |                                  |
| ### | IDENTIFICATION           |   |                                  |
|  F1 |                          |   |                                  |
+-----+--------------------------+---+----------------------------------+
| #   | RESPONDENT'S NAME:       |   |                                  |
| ### |                          |   |                                  |
|  F2 |                          |   |                                  |
+-----+--------------------------+---+----------------------------------+
|     | (Family Name, First      |   |                                  |
|     | Name)                    |   |                                  |
+-----+--------------------------+---+----------------------------------+
| #   | a\) INTERVIEW DATE       | \ |                                  |
| ### |                          | _ |                                  |
|  F3 | b\) STARTING TIME        | \ |                                  |
|     |                          | _ |                                  |
|     | c\) TIME INTERVIEW ENDED | \ |                                  |
|     |                          | _ |                                  |
|     | d\) TOTAL DURATION       | \ |                                  |
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+-----+--------------------------+---+----------------------------------+
| ##  | LANGUAGE                 | F |                                  |
|  F4 |                          | i |                                  |
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+-----+--------------------------+---+----------------------------------+
| ##  | ## COUNTRY               | * |                                  |
|  F5 |                          | * |                                  |
|     |                          | [ |                                  |
|     |                          | P |                                  |
|     |                          | h |                                  |
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|     |                          | . |                                  |
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|     |                          | } |                                  |
|     |                          | * |                                  |
|     |                          | * |                                  |
+-----+--------------------------+---+----------------------------------+
| **I |                          |   | **SUPERVIOR'S NAME:**            |
| NTE |                          |   |                                  |
| RVI |                          |   |                                  |
| EWE |                          |   |                                  |
| R'S |                          |   |                                  |
| N   |                          |   |                                  |
| AME |                          |   |                                  |
| :** |                          |   |                                  |
+-----+--------------------------+---+----------------------------------+

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 13%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 12%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 18%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><h6 id="section"> </h6>
<p id="section-2.-demographic-and-background-information"
class="heading">SECTION 2. Demographic and Background
Information</p></td>
</tr>
<tr class="even">
<td><p id="section-1" class="heading"></p></td>
<td colspan="7"><em>RECORD SEX AS OBSERVED</em></td>
<td colspan="6"><p>Female 1</p>
<p>Male 2</p></td>
</tr>
<tr class="odd">
<td><strong>1</strong></td>
<td colspan="7">Ilang taon na kayo sa kasalukuyan?</td>
<td colspan="6">___/___ years</td>
</tr>
<tr class="even">
<td><strong>2</strong></td>
<td colspan="7"><p>Sa kabuuan, ilang taon ang inyong ginugol sa
pag-aaral</p>
<p>sa eskuwelahan, kolehiyo o unibersidad?</p></td>
<td colspan="6">___/___ years</td>
</tr>
<tr class="odd">
<td rowspan="2"><strong>3</strong></td>
<td colspan="13"><p>Alin ang pinakamalapit na tumutukoy sa inyong estado
ng pangunahing hanapbuhay?</p>
<p><em><strong>(select the single best option)</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="4"><p>1 May hanapbuhay, na may suweldo 2 Sariling trabaho,
kagaya ng sariling</p>
<p>negosyo o pagsasaka 3 Walang bayad na trabaho, kagaya</p>
<p>ng boluntaryo o pagkakawanggawa</p></td>
<td colspan="4"><p>4 Estudyante</p>
<p>5 Gumaganap ng gawaing</p>
<p>bahay</p>
<p>6 Retirado</p></td>
<td colspan="5"><p>7 Walang hanapbuhay (dahil sa</p>
<p>kalusugan)</p>
<p>8 Walang hanapbuhay (iba pang</p>
<p>kadahilanan)</p>
<p>9 Iba pa (specify)</p></td>
</tr>
<tr class="odd">
<td><h4 id="section-2"></h4>
<h4 id="section-3">4</h4></td>
<td colspan="13"><p>Ano ang inyong kasalukuyang “marital status”?</p>
<p><em><strong>(select the single best option)</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="3"><p>1 Married</p>
<p>2 Widowed</p></td>
<td colspan="4"><p>3 Divorced</p>
<p>4 Separated</p></td>
<td colspan="5"><p>5 Never married</p>
<p>6 Living with partner</p></td>
<td colspan="2"><p>7 Don’t know/</p>
<p>Refused</p></td>
</tr>
<tr class="odd">
<td><h4 id="section-4"></h4>
<p><strong>A6</strong></p></td>
<td colspan="13">Magkano ang kabuuang kita ng inyong sambahayan? (See
card,)</td>
</tr>
<tr class="even">
<td><h4 id="section-5"></h4></td>
<td><p>J</p>
<p>R</p>
<p>C</p>
<p>M</p></td>
<td colspan="2"></td>
<td colspan="2"><p>F</p>
<p>S</p>
<p>K</p>
<p>P</p></td>
<td colspan="5"></td>
<td colspan="2"><p>D</p>
<p>H</p>
<p>U</p>
<p>N</p></td>
<td></td>
</tr>
<tr class="odd">
<td><h4 id="section-6"></h4>
<h4 id="a7">A7</h4></td>
<td colspan="13">Kabilang po kayo, ano po ang mga pangalan at edad ng
inyong mga kasamahan na nakatira dito sa inyong tahanan?</td>
</tr>
<tr class="even">
<td colspan="10"><strong>NAME</strong></td>
<td colspan="4"><strong>AGE</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>7</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>8</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>9</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>10</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>11</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>12</td>
<td colspan="9"></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

**Interviewer: Select one of the household members (other than the
respondent) to be interviewed for the proxy-reporting set of
questionnaire. Encircle the LINE No. of the selected member.**

######### VISION -- SELF-REPORT

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 24%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="17"><strong>Ang mga sumusunod na katanungan ay tungkol sa
kahirapan na inyong nararanasan sa paggawa sa inyong mga gawain dahil sa
PROBLEMA SA KALUSUGAN.</strong></td>
</tr>
<tr class="even">
<td colspan="2">1.</td>
<td colspan="3">(VSVISION)</td>
<td colspan="12"><h2
id="kayo-ba-ay-may-kahirapan-sa-paningin-kahit-kayo-ay-gumagamit-na-ng-salamin-sa-mata">Kayo
ba ay may kahirapan sa paningin, kahit kayo ay gumagamit na ng salamin
sa mata?</h2></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="5"></td>
<td colspan="3"></td>
<td colspan="9">Hindi, walang hirap (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Oo, kaunting hirap (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9">Oo, sobrang hirap (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Hindi kayang gawin (3)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="17">Did the respondent….</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">1.</td>
<td colspan="3">(VSREPE)</td>
<td colspan="5">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">2.</td>
<td colspan="3">(VSOPT)</td>
<td colspan="5">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">3.</td>
<td colspan="3">(VSCLARI)</td>
<td colspan="5">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="2">1.</td>
<td colspan="3">(VSWHY)</td>
<td colspan="12">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="2">2.</td>
<td colspan="3">(VSGLASS)</td>
<td colspan="12">Kayo ba ay palaging gumagamit ng salamin o sa tuwing
may ginagawa ka lamang o hindi ka gumagamit ng salamin?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"></td>
<td colspan="3"></td>
<td>Sa lahat ng oras (2)</td>
<td></td>
<td colspan="3">Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="2">Hindi gumagamit (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="17"><strong>3 – 4 Only if respondent reported any
difficulty seeing:</strong></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="3">(VSDIFF)</td>
<td colspan="12">[Kapag wala kang suot na salamin], gaano ka kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="9">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="17"><strong>Glasses wearers only:</strong></td>
</tr>
<tr class="even">
<td colspan="4">3a.</td>
<td colspan="3">(VSDIFFG)</td>
<td colspan="10">Kapag nakasuot ka na ng salamin, gaano ka kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="9">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----------------------- ---------- ---------- -------------- ------------- --------------- -------- ---- -----------------
  4\.                     (VSEFF)               \[Kapag wala                                               
                                                kang suot na                                               
                                                salamin\], sa                                              
                                                tuwing ikaw ay                                             
                                                nahihirapang                                               
                                                tumingin,                                                  
                                                gaano ang                                                  
                                                iyong                                                      
                                                ginagawang                                                 
                                                pagsisikap                                                 
                                                upang makakita                                             
                                                nang maayos?                                               

                                                               Walang                                      
                                                               pagsisikap                                  
                                                               (0)                                         

                                                               Kaunting                                    
                                                               pagsisikap                                  
                                                               (1)                                         

                                                               Sobrang                                     
                                                               pagsisikap                                  
                                                               (2)                                         

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   

  **Glasses wearers                                                                                        
  only:**                                                                                                  

  4a.                                (VSEFFG)   Kapag nakasuot                                             
                                                ka na ng                                                   
                                                salamin, gaano                                             
                                                ang iyong                                                  
                                                ginagawang                                                 
                                                pagsisikap                                                 
                                                upang makakita                                             
                                                nang maayos?                                               

                                                               Walang                                      
                                                               pagsisikap                                  
                                                               (0)                                         

                                                               Kaunting                                    
                                                               pagsisikap                                  
                                                               (1)                                         

                                                               Sobrang                                     
                                                               pagsisikap                                  
                                                               (2)                                         

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   

                                                                                                           

  [ASK                                                                                                     
  EVERYONE]{.underline}                                                                                    

  5\.                     (VSACT)               Mayroon bang                                               
                                                mga gawain na                                              
                                                hindi mo                                                   
                                                magawa dahil                                               
                                                sa problema mo                                             
                                                sa iyong                                                   
                                                paningin?                                                  

                                                               Wala (1)                                    

                                                               Mayroon (2)                                 
                                                               (Go to 5a.                                  
                                                               VSACTOPEN)                                  

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   

                                                                                                           

                                                5a.                          (VSACTOPEN)     Anong         
                                                                                             gawain        
                                                                                             iyon?         

                                                                                                           

  6\.                     (VSWORR)              Gaano ka                                                   
                                                nag-aalala o                                               
                                                nababahala sa                                              
                                                iyong                                                      
                                                paningin?                                                  

                                                               Hindi                                       
                                                               nag-aalala                                  
                                                               (0)                                         

                                                               Bahagyang                                   
                                                               nag-aalala                                  
                                                               (1)                                         

                                                               Sobrang                                     
                                                               nag-aalala                                  
                                                               (2)                                         

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   

                                                                                                           

  7\.                     (VSCOND)              May                                                        
                                                nakapagsabi na                                             
                                                ba sa iyong                                                
                                                dalubhasa sa                                               
                                                kalusugan na                                               
                                                mayroon kang                                               
                                                pinsala o                                                  
                                                sakit (katulad                                             
                                                ng katarata o                                              
                                                glaucoma) na                                               
                                                nakakaapekto                                               
                                                sa iyong                                                   
                                                paningin?                                                  

                                                               Oo (1)                                      Wala (0)

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   

                                                                                                           

  8\.                     (VSTEST)              Sa nakalipas                                               
                                                na dalawang                                                
                                                taon,                                                      
                                                naipasuri mo                                               
                                                na ba ang                                                  
                                                iyong                                                      
                                                paningin?                                                  

                                                               Oo (1)                                      Hindi (0)

                                                               *Walang                                     
                                                               sagot/hindi                                 
                                                               alam* (9)                                   
  ----------------------- ---------- ---------- -------------- ------------- --------------- -------- ---- -----------------

  --------- ------------- --------- ---------- ------------- -------------- -- ----------- ----------- ------------- ------------- -------------- ------------------------------------
  9\.       \[Kapag wala                                                                                                                          
            kang suot na                                                                                                                          
            salamin\],                                                                                                                            
            Kayo ba ay                                                                                                                            
            may                                                                                                                                   
            kahirapang. .                                                                                                                         
            .                                                                                                                                     

  a\.                               (VSNEAR)                                               Tumingin sa                                            
                                                                                           nakasulat                                              
                                                                                           sa mapa,                                               
                                                                                           pahayagan o                                            
                                                                                           diyaryo,                                               
                                                                                           libro o                                                
                                                                                           aklat?                                                 

                                                                                                                     Hindi                        
                                                                                                                     nahihirapan                  
                                                                                                                     (0)                          

                                                                                                                     Bahagyang                    
                                                                                                                     nahihirapan                  
                                                                                                                     (1)                          

                                                                                                                     Sobrang                      
                                                                                                                     nahihirapan                  
                                                                                                                     (2)                          

                                                                                                                     Hindi kayang                 
                                                                                                                     gawin (3)                    

                                                                                                                     *Walang                      
                                                                                                                     sagot/hindi                  
                                                                                                                     alam* (9)                    

                                                                                                                                                  

  b\.                     (VSFAR)                            Tumingin at                                                                          
                                                             makakilala ng                                                                        
                                                             isang tao na                                                                         
                                                             dati mo nang                                                                         
                                                             kakilala na                                                                          
                                                             nasa pitong                                                                          
                                                             metro                                                                                
                                                             (dalawampung                                                                         
                                                             talampakan)                                                                          
                                                             ang layo mula                                                                        
                                                             sa iyo?                                                                              

                                                                                                       Hindi                                      
                                                                                                       nahihirapan                                
                                                                                                       (0)                                        

                                                                                                       Bahagyang                                  
                                                                                                       nahihirapan                                
                                                                                                       (1)                                        

                                                                                                       Sobrang                                    
                                                                                                       nahihirapan                                
                                                                                                       (2)                                        

                                                                                                       Hindi kayang                               
                                                                                                       gawin (3)                                  

                                                                                                       *Walang                                    
                                                                                                       sagot/hindi                                
                                                                                                       alam* (9)                                  

                                                                                                                                                  

  Glasses                                                                                                                                         
  wearers                                                                                                                                         
  only:                                                                                                                                           

                                               9a. \[Kapag                                                                                        
                                               nakasuot ka                                                                                        
                                               na ng                                                                                              
                                               salamin\],                                                                                         
                                               Kayo ba ay                                                                                         
                                               may                                                                                                
                                               kahirapang. .                                                                                      
                                               .                                                                                                  

  a\.                                                                          (VSNEARG)                                           Tumingin sa    
                                                                                                                                   nakasulat sa   
                                                                                                                                   mapa,          
                                                                                                                                   pahayagan o    
                                                                                                                                   diyaryo, libro 
                                                                                                                                   o aklat?       

                                                                                                                                                  Hindi nahihirapan (0)

                                                                                                                                                  Bahagyang nahihirapan (1)

                                                                                                                                                  Sobrang nahihirapan (2)

                                                                                                                                                  Hindi kayang gawin (3)

                                                                                                                                                  *Walang sagot/hindi alam* (9)

                                                                                                                                                  

  b\.                                                                          (VSFARG)                                            Tumingin at    
                                                                                                                                   makakilala ng  
                                                                                                                                   isang tao na   
                                                                                                                                   dati mo nang   
                                                                                                                                   kakilala na    
                                                                                                                                   nasa pitong    
                                                                                                                                   metro          
                                                                                                                                   (dalawampung   
                                                                                                                                   talampakan)    
                                                                                                                                   ang layo mula  
                                                                                                                                   sa iyo?        

                                                                                                                                                  Hindi nahihirapan (0)

                                                                                                                                                  Bahagyang nahihirapan (1)

                                                                                                                                                  Sobrang nahihirapan (2)

                                                                                                                                                  Hindi kayang gawin (3)

                                                                                                                                                  *Walang sagot/hindi alam* (9)
  --------- ------------- --------- ---------- ------------- -------------- -- ----------- ----------- ------------- ------------- -------------- ------------------------------------

######### HEARING -- SELF-REPORT

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 16%" />
<col style="width: 6%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="3">(HSHEAR)</td>
<td colspan="11"><h2
id="kayo-ba-ay-may-kahirapan-sa-pandinig-kahit-kayo-ay-gumagamit-na-ng-hearing-aid">Kayo
ba ay may kahirapan sa pandinig, kahit kayo ay gumagamit na ng “hearing
aid”?</h2></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="17">Did the respondent….</td>
</tr>
<tr class="even">
<td colspan="2">1.</td>
<td colspan="4">(HSREPE)</td>
<td colspan="5">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td colspan="2">2.</td>
<td colspan="4">(HSOPT)</td>
<td colspan="5">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="4">(HSCLARI)</td>
<td colspan="5">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="4">(HSWHY)</td>
<td colspan="12">Bakit ninyo nasabi yon?</td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td>2.</td>
<td colspan="4">(HSAID)</td>
<td colspan="12">Kayo ba ay palaging gumagamit ng “hearing aid” o sa
tuwing may ginagawa ka lamang o hindi ka gumagamit ng “hearing
aid”?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Sa lahat ng oras (2)</td>
<td></td>
<td colspan="3">Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="2">Hindi gumagamit (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="17"><strong>3 – 4 Only if respondent reported any
difficulty hearing:</strong></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td>3.</td>
<td colspan="4">(HSDIFF)</td>
<td colspan="12">[Kapag wala kang “hearing aid”], gaano ka kadalas
nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="10">Hindi nahihirapan(0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="10">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="17"><strong>Hearing aid users only:</strong></td>
</tr>
<tr class="odd">
<td colspan="2">3a.</td>
<td colspan="4">(HSDIFFA)</td>
<td colspan="11">Kapag gumagamit ka ng “hearing aid”, gaano ka kadalas
nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="even">
<td colspan="6" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="9">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----------------------- ---------- ---------- --------------- ----- ------------- ------------- -------- ---- -------------------
  4\.                     (HSEFF)               \[Kapag wala                                                    
                                                kang "hearing                                                   
                                                aid"\], sa                                                      
                                                tuwing ikaw ay                                                  
                                                nahihirapang                                                    
                                                makarinig,                                                      
                                                gaano ang iyong                                                 
                                                ginagawang                                                      
                                                pagsisikap                                                      
                                                upang makarinig                                                 
                                                nang maayos?                                                    

                                                                      Walang                                    
                                                                      pagsisikap                                
                                                                      (0)                                       

                                                                      Kaunting                                  
                                                                      pagsisikap                                
                                                                      (1)                                       

                                                                      Sobrang                                   
                                                                      pagsisikap                                
                                                                      (2)                                       

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 

                                                                                                                

  **Hearing aid users                                                                                           
  only:**                                                                                                       

  4a.                                (HSEFFA)   Kapag gumagamit                                                 
                                                ka ng "hearing                                                  
                                                aid", gaano ang                                                 
                                                iyong                                                           
                                                ginagawang                                                      
                                                pagsisikap                                                      
                                                upang makarinig                                                 
                                                nang maayos?                                                    

                                                                      Walang                                    
                                                                      pagsisikap                                
                                                                      (0)                                       

                                                                      Kaunting                                  
                                                                      pagsisikap                                
                                                                      (1)                                       

                                                                      Sobrang                                   
                                                                      pagsisikap                                
                                                                      (2)                                       

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 

                                                                                                                

  [ASK                                                                                                          
  EVERYONE]{.underline}                                                                                         

  5\.                     (HSACT)               Mayroon bang                                                    
                                                mga gawain na                                                   
                                                hindi mo magawa                                                 
                                                dahil sa                                                        
                                                problema mo sa                                                  
                                                iyong pandinig?                                                 

                                                                      Wala (1)                                  

                                                                      Mayroon (2)                               
                                                                      (Go to 5a.                                
                                                                      HSACTOPEN)                                

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 

                                                                                                                

                                                                5a.                 (HSACTOPEN)   Anong         
                                                                                                  gawain        
                                                                                                  iyon?         

                                                                                                                

  6\.                     (HSWORR)              Gaano ka                                                        
                                                nag-aalala o                                                    
                                                nababahala sa                                                   
                                                iyong pandinig?                                                 

                                                                      Hindi                                     
                                                                      nag-aalala                                
                                                                      (0)                                       

                                                                      Bahagyang                                 
                                                                      nag-aalala                                
                                                                      (1)                                       

                                                                      Sobrang                                   
                                                                      nag-aalala                                
                                                                      (2)                                       

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 

                                                                                                                

  7\.                     (HSLOSS)              May nakapagsabi                                                 
                                                na ba sa iyong                                                  
                                                dalubhasa sa                                                    
                                                kalusugan na                                                    
                                                nawawalan ka ng                                                 
                                                pandinig?                                                       

                                                                      Oo (1)                                    Wala (2)

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 

                                                                                                                

  8\.                     (HSTEST)              Sa nakalipas na                                                 
                                                dalawang taon,                                                  
                                                nakapagpasuri                                                   
                                                ka na ba upang                                                  
                                                malaman mo kung                                                 
                                                ikaw ay                                                         
                                                nakakarinig                                                     
                                                nang maayos?                                                    

                                                                      Oo (1)                                    Hindi (2)

                                                                      *Walang                                   
                                                                      sagot/hindi                               
                                                                      alam* (9)                                 
  ----------------------- ---------- ---------- --------------- ----- ------------- ------------- -------- ---- -------------------

  --------- -------------- ------------ ------------- --------- ------------- ------------- ------------- --------- ------------- -------- ---- -------- -- ----------
  9\.       \[Kapag wala                                                                                                                                    
            kang "hearing                                                                                                                                   
            aid",\] Kayo                                                                                                                                    
            ba ay may                                                                                                                                       
            kahirapang                                                                                                                                      
            makarinig ng                                                                                                                                    
            inyong                                                                                                                                          
            pag-uusap...                                                                                                                                    

  a\.                      (HSCROWD)                  Sa isang                                                                                              
                                                      mataong                                                                                               
                                                      silid?                                                                                                

                                                                                            Hindi                                                           
                                                                                            nahihirapan                                                     
                                                                                            (0)                                                             

                                                                                            Bahagyang                                                       
                                                                                            nahihirapan                                                     
                                                                                            (1)                                                             

                                                                                            Sobrang                                                         
                                                                                            nahihirapan                                                     
                                                                                            (2)                                                             

                                                                                            Hindi kayang                                                    
                                                                                            gawin (3)                                                       

                                                                                            *Walang                                                         
                                                                                            sagot/hindi                                                     
                                                                                            alam* (9)                                                       

  b\.                      (HSQUIET)                  Sa isang                                                                                              
                                                      tahimik                                                                                               
                                                      na silid?                                                                                             

                                                                                            Hindi                                                           
                                                                                            nahihirapan                                                     
                                                                                            (0)                                                             

                                                                                            Bahagyang                                                       
                                                                                            nahihirapan                                                     
                                                                                            (1)                                                             

                                                                                            Sobrang                                                         
                                                                                            nahihirapan                                                     
                                                                                            (2)                                                             

                                                                                            Hindi kayang                                                    
                                                                                            gawin (3)                                                       

                                                                                            *Walang                                                         
                                                                                            sagot/hindi                                                     
                                                                                            alam* (9)                                                       

  Hearing                                                                                                                                                   
  aid users                                                                                                                                                 
  only:                                                                                                                                                     

                           9a. Kapag                                                                                                                        
                           gumagamit ka                                                                                                                     
                           ng "hearing                                                                                                                      
                           aid", kayo                                                                                                                       
                           ba ay may                                                                                                                        
                           kahirapang                                                                                                                       
                           makarinig ng                                                                                                                     
                           inyong                                                                                                                           
                           pag-uusap. .                                                                                                                     

  a\.                                   (HSCROWDA)                                                        Sa isang                                          
                                                                                                          mataong                                           
                                                                                                          silid?                                            

                                                                                                                    Hindi                                   
                                                                                                                    nahihirapan                             
                                                                                                                    (0)                                     

                                                                                                                    Bahagyang                               
                                                                                                                    nahihirapan                             
                                                                                                                    (1)                                     

                                                                                                                    Sobrang                                 
                                                                                                                    nahihirapan                             
                                                                                                                    (2)                                     

                                                                                                                    Hindi kayang                            
                                                                                                                    gawin (3)                               

                                                                                                                    *Walang                                 
                                                                                                                    sagot/hindi                             
                                                                                                                    alam* (9)                               

  b\.                                   (HSQUIETA)                                                        Sa isang                                          
                                                                                                          tahimik                                           
                                                                                                          na silid?                                         

                                                                                                                    Hindi                                   
                                                                                                                    nahihirapan                             
                                                                                                                    (0)                                     

                                                                                                                    Bahagyang                               
                                                                                                                    nahihirapan                             
                                                                                                                    (1)                                     

                                                                                                                    Sobrang                                 
                                                                                                                    nahihirapan                             
                                                                                                                    (2)                                     

                                                                                                                    Hindi kayang                            
                                                                                                                    gawin (3)                               

                                                                                                                    *Walang                                 
                                                                                                                    sagot/hindi                             
                                                                                                                    alam* (9)                               

  10\.      (HSMISS)                    Gaano mo                                                                                                            
                                        kadalas na                                                                                                          
                                        hindi marinig                                                                                                       
                                        ang ibang                                                                                                           
                                        salita sa                                                                                                           
                                        isang                                                                                                               
                                        pag-uusap o                                                                                                         
                                        kaya sa radyo                                                                                                       
                                        o telebisyon                                                                                                        
                                        dahil sa                                                                                                            
                                        iyong                                                                                                               
                                        kahirapan sa                                                                                                        
                                        pandinig?                                                                                                           

                                                                Araw-araw (2)                                                     Isang                     Hindi (0)
                                                                                                                                  beses sa                  
                                                                                                                                  isang                     
                                                                                                                                  linggo                    
                                                                                                                                  (1)                       

                                                                *Walang                                                                                     
                                                                sagot/hindi                                                                                 
                                                                alam* (9)                                                                                   

  11\.      (HSPROB)                    Madalas ka                                                                                                          
                                        bang                                                                                                                
                                        sinasabihan                                                                                                         
                                        ng iyong                                                                                                            
                                        kapamilya o                                                                                                         
                                        kasambahay na                                                                                                       
                                        may suliranin                                                                                                       
                                        o problema ka                                                                                                       
                                        sa pandinig?                                                                                                        

                                                                              Oo (1)                                                            Hindi       
                                                                                                                                                (2)         

                                                                              *Walang                                                                       
                                                                              sagot/hindi                                                                   
                                                                              alam* (9)                                                                     
  --------- -------------- ------------ ------------- --------- ------------- ------------- ------------- --------- ------------- -------- ---- -------- -- ----------

######### COGNITIVE -- SELF-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 13%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 22%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">3.</td>
<td colspan="4">(CSCOG)</td>
<td colspan="11"><h2
id="kayo-ba-ay-may-kahirapang-makaalala-o-mag-concentrate-magtuon-ng-pansin">Kayo
ba ay may kahirapang makaalala o mag-concentrate (magtuon ng
pansin)?</h2></td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Oo, konting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="7"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="18">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">1.</td>
<td colspan="2">(CSREPE)</td>
<td colspan="6">Need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">2.</td>
<td colspan="2">(CSOPT)</td>
<td colspan="6">Have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">3.</td>
<td colspan="2">(CSCLARI)</td>
<td colspan="6">Ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(CSWHY)</td>
<td colspan="13">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>2 – 5 Only if respondent reported any
difficulty remembering or concentrating:</strong></td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="2">2.</td>
<td colspan="3">(CSREMCON)</td>
<td colspan="13">Kayo ba ay may kahirapang makaalala o mag-concentrate
(magtuon ng pansin) o pareho?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"></td>
<td colspan="3"></td>
<td colspan="2">Makaalala (remembering) (1)</td>
<td></td>
<td colspan="3">Mag-concentrate (magtuon ng pansin) (2)</td>
<td colspan="2"></td>
<td colspan="2">Pareho (both) (3)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="2">3<strong>.</strong></td>
<td colspan="3">(CSDIFF)</td>
<td colspan="13">Gaano ka kadalas nahihirapang makaalala o
mag-concentrate (magtuon ng pansin) nang maayos?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="10">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="2">4.</td>
<td colspan="3">(CSEFF)</td>
<td colspan="13">Sa tuwing ikaw ay nahihirapan, gaano ang iyong
ginagawang pagsisikap upang makaalala o makapag-concentrate (makapagtuon
ng pansin)?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="10">Walang pagsisiskap (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10">Kaunting pagsisikap (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10">Sobrang pagsisikap (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----------------------- ------------ ------------ --------------------- ----- ------------- ----------------- ------------- -------- -- -------- -------- ---- -------------------
  5\.                     (CSCAUSE)                 Kayo ba ay naniniwala                                                                                        
                                                    na ang iyong                                                                                                 
                                                    kahirapang makaalala                                                                                         
                                                    o makapag-concentrate                                                                                        
                                                    (makapagtuon ng                                                                                              
                                                    pansin) ay... \[MARK                                                                                         
                                                    ALL THAT APPLY\]                                                                                             

                                                                                              dahil sa marami                                                    
                                                                                              kang ginagawa?                                                     
                                                                                              (1)                                                                

                                                                                              dahil sa iyong                                                     
                                                                                              pagtanda? (2)                                                      

                                                                                              o dahil sa iba                                                     
                                                                                              pang kadahilanan?                                                  
                                                                                              (3)                                                                

                                                                                              *Walang                                                            
                                                                                              sagot/hindi alam*                                                  
                                                                                              (9)                                                                

  [ASK                                                                                                                                                           
  EVERYONE]{.underline}                                                                                                                                          

  6\.                     (CSACT)                   Mayroon bang mga                                                                                             
                                                    gawain na hindi mo                                                                                           
                                                    magawa dahil sa                                                                                              
                                                    problema mong                                                                                                
                                                    makaalala o                                                                                                  
                                                    makapag-concentrate                                                                                          
                                                    (makapagtuon ng                                                                                              
                                                    pansin)?                                                                                                     

                                                                                              Wala (1)                                                           

                                                                                              Mayroon (2) (Go                                                    
                                                                                              to 6a. CSACTOPEN)                                                  

                                                                                              *Walang                                                            
                                                                                              sagot/hindi alam*                                                  
                                                                                              (9)                                                                

                                                                                                                                                                 

                                                                          6a.                                   (CSACTOPEN)               Anong                  
                                                                                                                                          gawain                 
                                                                                                                                          iyon?                  

                                                                                                                                                                 

  7\.                     (CSWORR)                  Gaano ka nag-aalala o                                                                                        
                                                    nababahala sa iyong                                                                                          
                                                    kakayahang makaalala                                                                                         
                                                    o makapag-concentrate                                                                                        
                                                    (magtuon ng pansin)?                                                                                         

                                                                                Hindi                                                                            
                                                                                nag-aalala                                                                       
                                                                                (0)                                                                              

                                                                                Bahagyang                                                                        
                                                                                nag-aalala                                                                       
                                                                                (1)                                                                              

                                                                                Sobrang                                                                          
                                                                                nag-aalala                                                                       
                                                                                (2)                                                                              

                                                                                *Walang                                                                          
                                                                                sagot/hindi                                                                      
                                                                                alam* (9)                                                                        

  8\.                     Kayo ba ay                                                                                                                             
                          may                                                                                                                                    
                          kahirapan. .                                                                                                                           
                          .                                                                                                                                      

                                                                                                                                                                 

  a\.                                  (CSNAMES)                                              Sa pag-alala ng                                                    
                                                                                              mga pangalan ng                                                    
                                                                                              tao o lugar?                                                       

                                                                                                                              Oo (1)               Hindi         *Walang sagot/hindi
                                                                                                                                                   (2)           alam* (9)

                                                                                                                                                                 

  b\.                                  (CSAPPT)                                               Sa pag-alala ng                                                    
                                                                                              pinagkasunduang                                                    
                                                                                              pagkikita                                                          
                                                                                              (appointments)?                                                    

                                                                                                                              Oo (1)               Hindi         *Walang sagot/hindi
                                                                                                                                                   (2)           alam* (9)

                                                                                                                                                                 

  c\.                                  (CSPLACES)                                             Sa pag-alala kung                                                  
                                                                                              paano makarating                                                   
                                                                                              sa pamilyar na                                                     
                                                                                              lugar?                                                             

                                                                                                                              Oo (1)               Hindi         *Walang sagot/hindi
                                                                                                                                                   (2)           alam* (9)

                                                                                                                                                                 

  d\.                                  (CSTASKS)                                              Sa pag-alala ng                                                    
                                                                                              mga mahahalagang                                                   
                                                                                              gawain, gaya ng                                                    
                                                                                              pag-inom ng gamot                                                  
                                                                                              o pagbabayad ng                                                    
                                                                                              mga bayarin?                                                       

                                                                                                                              Oo (1)               Hindi         *Walang sagot/hindi
                                                                                                                                                   (2)           alam* (9)
  ----------------------- ------------ ------------ --------------------- ----- ------------- ----------------- ------------- -------- -- -------- -------- ---- -------------------

  ------ ----------- --------------------- -------------------------------------------------
  9\.    (CSTEN)     Kayo ba ay may        
                     kahirapang            
                     makapag-concentrate   
                     (makapagtuon ng       
                     pansin) sa paggawa ng 
                     isang bagay sa loob   
                     ng sampung minuto?    

                                           Hindi nahihirapan (0)

                                           Bahagyang nahihirapan (1)

                                           Sobrang nahihirapan (2)

                                           Hindi kayang gawin (3)

                                           *Walang sagot/hindi alam* (9)

                                           

  10\.   (CSNEW)     Kayo ba ay may        
                     kahirapang matutunan  
                     ang isang bagong      
                     gawain, halimbawa,    
                     matutong makarating   
                     sa bagong lugar?      

                                           Hindi nahihirapan (0)

                                           Bahagyang nahihirapan (1)

                                           Sobrang nahihirapan (2)

                                           Hindi kayang gawin (3)

                                           *Walang sagot/hindi alam* (9)

                                           

  11\.   (CSSOLUT)   Kayo ba ay may        
                     kahirapang makahanap  
                     ng solusyon sa mga    
                     problema sa           
                     pang-araw-araw mong   
                     pamumuhay?            

                                           Hindi nahihirapan (0)

                                           Bahagyang nahihirapan (1)

                                           Sobrang nahihirapan (2)

                                           Hindi kayang gawin (3)

                                           *Walang sagot/hindi alam* (9)
  ------ ----------- --------------------- -------------------------------------------------

LOWER MOBILITY -- SELF-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 13%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">4.</td>
<td colspan="2">(MSWALK)</td>
<td colspan="13"><h2
id="kayo-ba-ay-may-kahirapan-sa-paglalakad-o-pag-akyat-sa-hagdan">Kayo
ba ay may kahirapan sa paglalakad o pag-akyat sa hagdan?</h2></td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="11">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="11">Oo, konting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="11">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="11">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="11"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="18">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">1.</td>
<td colspan="2">(MSREPE)</td>
<td colspan="6">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">2.</td>
<td colspan="2">(MSOPT)</td>
<td colspan="6">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">3.</td>
<td colspan="2">(MSCLARI)</td>
<td colspan="6">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(MSWHY)</td>
<td colspan="13">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(MSAID)</td>
<td colspan="13">Kayo ba ay gumagamit ng mga kagamitan katulad ng
wheelchair, panggabay sa paglakad o tungkod upang kayo ay matulungan sa
pagkilos?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="3"></td>
<td colspan="3"></td>
<td colspan="10">Wala (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10">Mayroon (1) (<em>Go to 2a. MSAIDTYPE</em>)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="5">2a.</td>
<td colspan="4">(MSAIDTYPE)</td>
<td colspan="9">Anong kagamitan ang ginagamit mo?</td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="18"><strong>3 – 5 Only if respondent reported any
difficulty walking or climbing steps:</strong></td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="3">(MSWALKSTEP)</td>
<td colspan="13">Kayo ba ay may kahirapan sa paglalakad o pag-akyat sa
hagdan o pareho?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"></td>
<td colspan="3"></td>
<td colspan="2">Paglalakad (1)</td>
<td></td>
<td colspan="3">Pag-akyat (2)</td>
<td></td>
<td colspan="3">Pareho (3)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="3">(MSDIFF)</td>
<td colspan="13">[Kapag wala kang kagamitan, ….] Gaano ka kadalas
nahihirapang maglakad o umakyat sa hagdan?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="10">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="10">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ------------------------- ---------- ------------- -------------- ----------- ------------- ------------- -------------- ---------------- --------------------------------------
                                       **Equipment                                                                                          
                                       users only:**                                                                                        

  4a.                                                               (MSDIFFA)                               Kapag gamit mo                  
                                                                                                            ang iyong                       
                                                                                                            kagamitan,                      
                                                                                                            gaano ka                        
                                                                                                            kadalas                         
                                                                                                            nahihirapang                    
                                                                                                            maglakad o                      
                                                                                                            umakyat sa                      
                                                                                                            hagdan?                         

                                                                                                                           Hindi            
                                                                                                                           Nahihirapan(0)   

                                                                                                                           Medyo madalas    
                                                                                                                           (1)              

                                                                                                                           Sobrang dalas    
                                                                                                                           (2)              

                                                                                                                           *Walang          
                                                                                                                           sagot/hindi      
                                                                                                                           alam* (9)        

                                                                                                                                            

  5\.                       (MSEFF)                  Sa tuwing ikaw                                                                         
                                                     ay nahihirapan                                                                         
                                                     \[kapag hindi                                                                          
                                                     mo gamit ang                                                                           
                                                     iyong                                                                                  
                                                     kagamitan\],                                                                           
                                                     gaano ang                                                                              
                                                     iyong                                                                                  
                                                     ginagawang                                                                             
                                                     pagsisikap                                                                             
                                                     upang                                                                                  
                                                     makalakad o                                                                            
                                                     makaakyat sa                                                                           
                                                     hagdan?                                                                                

                                                                                Walang                                                      
                                                                                pagsisikap                                                  
                                                                                (0)                                                         

                                                                                Kaunting                                                    
                                                                                pagsisikap                                                  
                                                                                (1)                                                         

                                                                                Sobrang                                                     
                                                                                pagsisikap                                                  
                                                                                (2)                                                         

                                                                                *Walang                                                     
                                                                                sagot/hindi                                                 
                                                                                alam* (9)                                                   

                                                                                                                                            

                                       **Equipment                                                                                          
                                       users only:**                                                                                        

  5a.                                                               (MSEFFA)                                Kapag gamit mo                  
                                                                                                            ang iyong                       
                                                                                                            kagamitan,                      
                                                                                                            gaano ang                       
                                                                                                            iyong                           
                                                                                                            ginagawang                      
                                                                                                            pagsisikap                      
                                                                                                            upang                           
                                                                                                            makalakad o                     
                                                                                                            makaakyat sa                    
                                                                                                            hagdan?                         

                                                                                                                           Walang           
                                                                                                                           pagsisikap (0)   

                                                                                                                           Kaunting         
                                                                                                                           pagsisikap (1)   

                                                                                                                           Sobrang          
                                                                                                                           pagsisikap (2)   

                                                                                                                           *Walang          
                                                                                                                           sagot/hindi      
                                                                                                                           alam* (9)        

                                                                                                                                            

  **[ASK                                                                                                                                    
  EVERYONE]{.underline}**                                                                                                                   

  6\.                       (MSACT)                  Mayroon bang                                                                           
                                                     mga gawain na                                                                          
                                                     hindi mo                                                                               
                                                     magawa dahil                                                                           
                                                     sa problema mo                                                                         
                                                     sa iyong                                                                               
                                                     binti?                                                                                 

                                                                                Wala (1)                                                    

                                                                                Mayroon (2)                                                 

                                                                                *Walang                                                     
                                                                                sagot/hindi                                                 
                                                                                alam* (9)                                                   

                                                                                                                                            

                                                                    6a.                       (MSACTOPEN)                                   Anong gawain iyon?

                                                                                                                                            

                                                                                                                                            

  7\.                       (MSWORR)                 Gaano ka                                                                               
                                                     nag-aalala o                                                                           
                                                     nababahala sa                                                                          
                                                     iyong                                                                                  
                                                     kakayahang                                                                             
                                                     makalakad o                                                                            
                                                     maka-akyat sa                                                                          
                                                     hagdan?                                                                                

                                                                                Hindi                                                       
                                                                                nag-aalala                                                  
                                                                                (0)                                                         

                                                                                Bahagyang                                                   
                                                                                nag-aalala                                                  
                                                                                (1)                                                         

                                                                                Sobrang                                                     
                                                                                nag-aalala                                                  
                                                                                (2)                                                         

                                                                                *Walang                                                     
                                                                                sagot/hindi                                                 
                                                                                alam* (9)                                                   
  ------------------------- ---------- ------------- -------------- ----------- ------------- ------------- -------------- ---------------- --------------------------------------

  ------ ------------------ ------------- ------------ ------------- ----------- -------------------- ---- --------------
  8\.    (MSINSIDE)                       Kayo ba ay                                                       
                                          may                                                              
                                          kahirapang                                                       
                                          kumilos sa                                                       
                                          loob ng                                                          
                                          iyong                                                            
                                          tahanan?                                                         

                                                       Hindi kayang                                        
                                                       gawin (3)                                           

                                                       Sobrang                                             
                                                       nahihirapan                                         
                                                       (2)                                                 

                                                       Bahagyang                                           
                                                       nahihirapan                                         
                                                       (1)                                                 

                                                       Hindi                                               
                                                       nahihirapan                                         
                                                       (0)                                                 

                                                       *Walang                                             
                                                       sagot/hindi                                         
                                                       alam* (9)                                           

  9\.    (MSOUTSIDE)                      Kayo ba ay                                                       
                                          may                                                              
                                          kahirapang                                                       
                                          lumabas sa                                                       
                                          iyong                                                            
                                          tahanan?                                                         

                                                       Hindi kayang                                        
                                                       gawin (3)                                           

                                                       Sobrang                                             
                                                       nahihirapan                                         
                                                       (2)                                                 

                                                       Bahagyang                                           
                                                       nahihirapan                                         
                                                       (1)                                                 

                                                       Hindi                                               
                                                       nahihirapan                                         
                                                       (0)                                                 

                                                       *Walang                                             
                                                       sagot/hindi                                         
                                                       alam* (9)                                           

  10\.   (MSLONG)                         Kayo ba ay                                                       
                                          may                                                              
                                          kahirapang                                                       
                                          maglakad ng                                                      
                                          malayo                                                           
                                          kagaya ng                                                        
                                          isang                                                            
                                          kilometro?                                                       

                                                       Hindi                                               
                                                       nahihirapan                                         
                                                       (0)                                                 

                                                       Bahagyang                                           
                                                       nahihirapan                                         
                                                       (1)                                                 

                                                       Sobrang                                             
                                                       nahihirapan                                         
                                                       (2)                                                 

                                                       Hindi kayang                                        
                                                       gawin (3)                                           

                                                       *Walang                                             
                                                       sagot/hindi                                         
                                                       alam* (9)                                           

  11\.   Kung ikaw lang at                                                                                 
         walang                                                                                            
         gamit-pantulong,                                                                                  
         kayo ba ay may                                                                                    
         kahirapang ...                                                                                    

  a\.                       (MSQUARTER)                              Maglakad ng                           
                                                                     ika-apat na                           
                                                                     bahagi ng                             
                                                                     milya ang                             
                                                                     layo (mga                             
                                                                     dalawa                                
                                                                     hanggang                              
                                                                     tatlong                               
                                                                     kanto)?                               

                                                                                 Oo (1)                    Hindi (2)

                                                                                 *Walang sagot/hindi       
                                                                                 alam* (9)                 

  b\.                       (MSSTEPS)                                Umakyat ng                            
                                                                     sampung                               
                                                                     hakbang na                            
                                                                     walang                                
                                                                     pahinga?                              

                                                                                 Oo (1)                    Hindi (2)

                                                                                 *Walang sagot/hindi       
                                                                                 alam* (9)                 

  c\.                       (MSSTAND)                                Tumayo sa                             
                                                                     iyong mga                             
                                                                     paa ng                                
                                                                     dalawang                              
                                                                     oras?                                 

                                                                                 Oo (1)                    Hindi (2)

                                                                                 *Walang sagot/hindi       
                                                                                 alam* (9)                 

  d\.                       (MSSIT)                                  Umupo sa                              
                                                                     loob ng                               
                                                                     dalawang                              
                                                                     oras?                                 

                                                                                 Oo (1)                    Hindi (2)

                                                                                 *Walang sagot/hindi       
                                                                                 alam* (9)                 

  e\.                       (MSSTOOP)                                Yumuko,                               
                                                                     yumukyuk, o                           
                                                                     lumuhod?                              

                                                                                 Oo (1)                    Hindi (2)

                                                                                 *Walang sagot/hindi       
                                                                                 alam* (9)                 
  ------ ------------------ ------------- ------------ ------------- ----------- -------------------- ---- --------------

######### SELF-CARE -- SELF-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 13%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 39%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">5.</td>
<td colspan="2">(SSSCARE)</td>
<td colspan="7"><h2
id="kayo-ba-ay-may-kahirapan-sa-pag-aalaga-ng-iyong-sarili-katulad-ng-pagligo-o-pagbihis">Kayo
ba ay may kahirapan sa pag-aalaga ng iyong sarili, katulad ng pagligo o
pagbihis? </h2></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="5">Hindi, walang hirap (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Oo, kaunnting hirap (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Oo, sobrang hirap (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Hindi kayang gawin (3)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="12">Did the respondent….</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">1.</td>
<td colspan="2">(SSREPE)</td>
<td colspan="2">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td>Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">2.</td>
<td colspan="2">(SSOPT)</td>
<td colspan="2">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td>Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">3.</td>
<td colspan="2">(SSCLARI)</td>
<td colspan="2">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td>Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(SSWHY)</td>
<td colspan="7">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>2 – 3 Only if Respondent reported any
difficulty with self-care:</strong></td>
</tr>
<tr class="even">
<td colspan="2">2<strong>.</strong></td>
<td colspan="3">(SSDIFF)</td>
<td colspan="7">Gaano ka kadalas nahihirapang mag-alaga ng iyong
sarili?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nahihirapan(0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="3">(SSEFF)</td>
<td colspan="7">Sa tuwing ikaw ay nahihirapan, gaano ang iyong
ginagawang pagsisikap upang maalagaan ang iyong sarili?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Walang pagsisikap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Kaunting pagsisikap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Sobrang pagsisikap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="12"><strong><u>ASK EVERYONE</u></strong></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="3">(SSWORR)</td>
<td colspan="7">Gaano ka nag-aalala o nababahala sa iyong kakayahang
maalagaan ang iyong sarili?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nag-aalala (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Sobrang nag-aalala (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----- ------------------ ------------ ----------------- ------------------------- ---- -------------------
  5\.   Kung ikaw lang at                                                                
        walang                                                                           
        gamit-pantulong,                                                                 
        kayo ba ay may                                                                   
        kahirapang ...                                                                   

  a\.                      (SSHEAD)     Umabot ng                                        
                                        lampas-ulo?                                      

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  b\.                      (SSHAND)     Iabot ang iyong                                  
                                        kamay para                                       
                                        makipagkamay?                                    

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  c\.                      (SSFINGER)   Gamitin ang iyong                                
                                        mga daliri upang                                 
                                        mai-butones ang                                  
                                        kamiseta o damit?                                

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  d\.                      (SSSOCK)     Magsuot ng medyas                                
                                        o 'stockings'?                                   

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  e\.                      (SSSHOE)     Magtali ng sintas                                
                                        ng sapatos?                                      

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  f\.                      (SSHAIR)     Magsuklay ng                                     
                                        buhok?                                           

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  g\.                      (SSFEED)     Pakainin ang                                     
                                        sarili?                                          

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  6\.   (SSDAILY)                       Kayo ba ay                                       
                                        nangangailangan                                  
                                        ng taong tutulong                                
                                        sa pang-araw-araw                                
                                        mong gawain                                      
                                        kagaya ng                                        
                                        pagkain, pagligo,                                
                                        pagbihis o                                       
                                        pagpunta sa                                      
                                        palikuran?                                       

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  7\.   (SSOBJECTS)                     Kayo ba ay may                                   
                                        kahirapang                                       
                                        gamitin ang iyong                                
                                        mga kamay at                                     
                                        daliri, kagaya ng                                
                                        pagpulot ng                                      
                                        maliliit na bagay                                
                                        o pagbukas o                                     
                                        pagsara ng mga                                   
                                        lalagyan?                                        

                                                          Hindi nahihirapan (0)          

                                                          Bahagyang nahihirapan (1)      

                                                          Sobrang nahihirapan (2)        

                                                          Hindi kayang gawin (3)         

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            

  8\.   (SSTIRED)                       Kayo ba ay                                       
                                        nakakaramdam ng                                  
                                        matinding pagod o                                
                                        lungkot na                                       
                                        magbihis o                                       
                                        maligo?                                          

                                                          Oo (1)                         Hindi (2)

                                                          *Walang sagot/hindi alam*      
                                                          (9)                            
  ----- ------------------ ------------ ----------------- ------------------------- ---- -------------------

######### COMMUNICATION -- SELF-REPORT

  ------------------------- ----- ---------- ---------- ----------- ----------------------------- -------------------------- ---- ---------- -- -------
  6\.                                        (TSCOMM)               Sa kadahilanang pisikal,                                                    
                                                                    mental o pang-emosyon na                                                    
                                                                    kalagayan ng kalusugan, kayo                                                
                                                                    ba ay may kahirapan sa                                                      
                                                                    pakikipag-usap, halimbawa ay                                                
                                                                    maintindihan ang sinasabi ng                                                
                                                                    iba o maintindihan kayo?                                                    

                                                                                                                                                

                                                                                                  Hindi, walang hirap (0)                       

                                                                                                  Oo, kaunting hirap (1)                        

                                                                                                  Oo, sobrang hirap (2)                         

                                                                                                  Hindi kayang gawin (3)                        

                                                                                                  *Walang sagot/hindi alam*                     
                                                                                                  (9)                                           

                                                                                                                                                

  Did the respondent....                                                                                                                        

                            1\.                         (TSREPE)    need you to                                                   Yes (1)       No (2)
                                                                    [repeat]{.underline} any part                                               
                                                                    of the question?                                                            

                            2\.                         (TSOPT)     have any difficulty using the                                 Yes (1)       No (2)
                                                                    [response                                                                   
                                                                    options]{.underline}?                                                       

                            3\.                         (TSCLARI)   ask for                                                       Yes (1)       No (2)
                                                                    [clarification]{.underline}                                                 
                                                                    or qualify their answer?                                                    

                                                                                                                                                

  1\.                                        (TSWHY)                Bakit ninyo nasabi iyon?                                                    

                                                                                                                                                

  **2 -- 3 Only if                                                                                                                              
  Respondent reported any                                                                                                                       
  difficulty with                                                                                                                               
  communication:**                                                                                                                              

  2**.**                          (TSDIFF)                          Gaano ka kadalas nahihirapang                                               
                                                                    umintindi o maintindihan?                                                   

                                                                                                  Hindi nahihirapan(0)                          

                                                                                                  Medyo madalas (1)                             

                                                                                                  Sobrang dalas (2)                             

                                                                                                  *Walang sagot/hindi alam*                     
                                                                                                  (9)                                           

  3\.                             (TSEFF)                           Sa tuwing ikaw ay                                                           
                                                                    nahihirapan, gaano ang iyong                                                
                                                                    ginagawang pagsisikap upang                                                 
                                                                    makaintindi o maintindihan?                                                 

                                                                                                  Walang pagsisikap (0)                         

                                                                                                  Kaunting pagsisikap (1)                       

                                                                                                  Sobrang pagsisikap (2)                        

                                                                                                  *Walang sagot/hindi alam*                     
                                                                                                  (9)                                           

  **[ASK                                                                                                                                        
  EVERYONE]{.underline}**                                                                                                                       

  4\.                             (TSWORR)                          Gaano ka nag-aalala o                                                       
                                                                    nababahala sa iyong kakayahan                                               
                                                                    upang umintindi o                                                           
                                                                    maintindihan ka?                                                            

                                                                                                  Hindi nag-aalala (0)                          

                                                                                                  Bahagyang nag-aalala (1)                      

                                                                                                  Sobrang nag-aalala (2)                        

                                                                                                  *Walang sagot/hindi alam*                     
                                                                                                  (9)                                           
  ------------------------- ----- ---------- ---------- ----------- ----------------------------- -------------------------- ---- ---------- -- -------

  ----- ------------- ------------------ ------------------------ ---- --------------------
  5\.   (TSSAY)       Kayo ba ay may                                   
                      kahirapang                                       
                      maintindihan ang                                 
                      sinasabi ng mga                                  
                      tao?                                             

                                         Hindi nahihirapan (0)         

                                         Bahagyang nahihirapan         
                                         (1)                           

                                         Sobrang nahihirapan (2)       

                                         Hindi kayang gawin (3)        

                                         *Walang sagot/hindi           
                                         alam* (9)                     

                                                                       

  6\.   (TSCONVO)     Kayo ba ay may                                   
                      kahirapang                                       
                      magsimula at                                     
                      magpatuloy ng                                    
                      isang pag-uusap?                                 

                                         Hindi nahihirapan (0)         

                                         Bahagyang nahihirapan         
                                         (1)                           

                                         Sobrang nahihirapan (2)       

                                         Hindi kayang gawin (3)        

                                         *Walang sagot/hindi           
                                         alam* (9)                     

                                                                       

  7\.   (TSFRIEND)    Kayo ba ay may                                   
                      kahirapang                                       
                      makipagkaibigan?                                 

                                         Oo (1)                        Hindi (2)

                                         *Walang sagot/hindi           
                                         alam* (9)                     

                                                                       

  8\.   (TSSHY)       Kayo ba ay                                       
                      nakakaramdam ng                                  
                      hiya sa pagtitipon                               
                      o salu-salo?                                     

                                         Oo (1)                        Hindi (2)

                                         *Walang sagot/hindi           
                                         alam* (9)                     
  ----- ------------- ------------------ ------------------------ ---- --------------------

######### GENERAL HEALTH -- SELF-REPORT

  ---------------- ----- ------------- ----------- ------------- ----------------------------- --------------------- ---- --------- -------------------- ---- --------- -- -- ------------- ------- ---- ---------
  7\.                    (GSHEALTH)                                                            Sa kabuuan, masasabi                                                                                      
                                                                                               mo ba na ang iyong                                                                                        
                                                                                               kalusugan ay                                                                                              
                                                                                               napakaganda, sobrang                                                                                      
                                                                                               maganda, maganda,                                                                                         
                                                                                               katamtamang ganda o                                                                                       
                                                                                               hindi maganda?                                                                                            

                                                                                                                                                                                                         

                                                   Napakaganda                                                            Sobrang                             Maganda         Katamtamang                Hindi
                                                   (4)                                                                    maganda                             (2)             ganda (1)                  maganda
                                                                                                                          (3)                                                                            (0)

                                                   *Walang                                                                                                                                               
                                                   sagot/hindi                                                                                                                                           
                                                   alam* (9)                                                                                                                                             

  Did the                                                                                                                                                                                                
  respondent....                                                                                                                                                                                         

                   1\.                 (GSREPE)                  need you to                                                                                                                Yes (1)      No (2)
                                                                 [repeat]{.underline} any part                                                                                                           
                                                                 of the question?                                                                                                                        

                   2\.                 (GSOPT)                   have any difficulty using the                                                                                              Yes (1)      No (2)
                                                                 [response                                                                                                                               
                                                                 options]{.underline}?                                                                                                                   

                   3\.                 (GSCLARI)                 ask for                                                                                                                    Yes (1)      No (2)
                                                                 [clarification]{.underline}                                                                                                             
                                                                 or qualify their answer?                                                                                                                

  1\.                    (GSWHY)                                                               Bakit ninyo nasabi                                                                                        
                                                                                               iyon?                                                                                                     

                                                                                                                                                                                                         

  2**.**                 (GSWHYCODE)                                                           *Was the respondent                                                                                       
                                                                                               thinking about: (Mark                                                                                     
                                                                                               all that apply)*                                                                                          

                         *Physical*                                                            **\-\-\-\-\-\-\--**                  \(1\)                                                                

                         *Mental*                                                              **\-\-\-\-\-\-\--**                  \(2\)                                                                

                         *Spiritual*                                                           **\-\-\-\-\-\-\--**                  \(3\)                                                                

  3\.                    (GSCOND)                                                              Kayo ba ay mayrooon                                                                                       
                                                                                               sa mga sumusunod?                                                                                         

                                                                                                                                    Hika/nahihirapan sa                                                  
                                                                                                                                    paghinga (1)                                                         

                                                                                                                                    Pamamaga ng                                                          
                                                                                                                                    kasu-kasuan/rayuma                                                   
                                                                                                                                    (2)                                                                  

                                                                                                                                    Problema sa likod o                                                  
                                                                                                                                    leeg (3)                                                             

                                                                                                                                    Pagkabali ng                                                         
                                                                                                                                    buto/pinsala ng                                                      
                                                                                                                                    kasu-kasuan (4)                                                      

                                                                                                                                    Sakit sa puso (5)                                                    

                                                                                                                                    Stroke (6)                                                           

                                                                                                                                    Mataas ang presyon                                                   
                                                                                                                                    ng dugo (7)                                                          

                                                                                                                                    Diyabetis (8)                                                        

                                                                                                                                    Kancer (10)                                                          

                                                                                                                                    Kakulangan sa                                                        
                                                                                                                                    pag-iisip (11)                                                       

                                                                                                                                    Developmental                                                        
                                                                                                                                    problem (12)                                                         

                                                                                                                                    Problema sa emosyon                                                  
                                                                                                                                    (13)                                                                 

                                                                                                                                    Walang paa, bisig o                                                  
                                                                                                                                    braso (14)                                                           

                                                                                                                                    Sakit sa bato,                                                       
                                                                                                                                    pantog o pag-ihi                                                     
                                                                                                                                    (15)                                                                 

                                                                                                                                    Neurological                                                         
                                                                                                                                    disorder (16)                                                        

                                                                                                                                    *No Answer/Don't                                                     
                                                                                                                                    Know* (9)                                                            
  ---------------- ----- ------------- ----------- ------------- ----------------------------- --------------------- ---- --------- -------------------- ---- --------- -- -- ------------- ------- ---- ---------

######### INTERVIEWER DEBRIEFING

  --------------- ------------- --------------- -------------- ----------------- -------- ------------------------------------------------------------
  **Interviewer                                                                           
  Answer:**                                                                               

  1\.             (IATMO)                       During the                                
                                                interview ,                               
                                                was the                                   
                                                atmosphere at                             
                                                the interview                             
                                                site:                                     

                                                               1\. Extremely              
                                                               chaotic and                
                                                               noisy; disruptive          
                                                               to interview               

                                                               2\. Some noisy             
                                                               and                        
                                                               interruptions,             
                                                               but interview              
                                                               went reasonably            
                                                               well                       

                                                               3\. Very quiet             
                                                               and calm; ideal            
                                                               for interview              

  2\.             (IWHERE)                      Where did the                             
                                                interview take                            
                                                place?                                    

                                                               1\. Home                   

                                                               2\. Office                 

                                                               3\. Outside                

  3\.             (IHEAR)                       Were there any                            
                                                other people                              
                                                in the same                               
                                                room or near                              
                                                enough to                                 
                                                overhear the                              
                                                interview?                                

                                                               1\. Yes, *(Go to           
                                                               3a)*                       

                                                               3a.               (IWHO)   Who were the people?
                                                                                          \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

                                                               2\. No                     

  4\.             (IIMPAIR)                     Did the                                   
                                                respondent                                
                                                have any of                               
                                                the following                             
                                                impairments                               
                                                making it                                 
                                                difficult to                              
                                                respond?                                  

                                                               1\. Mentally               
                                                               handicapped                

                                                               2\. Hard of                
                                                               hearing/hearing            
                                                               impaired                   

                                                               3\. Poor                   
                                                               eyesight/vision            
                                                               impaired                   

                                                               4\. Speech                 
                                                               impediment                 

                                                               5\. Poor language          
                                                               abilities                  

                                                               6\. Under the              
                                                               influence of               
                                                               alcohol or drugs           

                                                               7\. Some other             
                                                               impairment                 

                                                               9\. None                   

  5\.             (IVOCAB)                      How would you                             
                                                describe the                              
                                                respondent's                              
                                                vocabulary                                
                                                (the variety                              
                                                of words the                              
                                                respondent                                
                                                used to                                   
                                                describe                                  
                                                his/her                                   
                                                thoughts)?                                

                                                               1\. Below average          

                                                               2\. Average                

                                                               3\. Above average          

  6\.             (IACT)                        In general,                               
                                                how did the                               
                                                respondent act                            
                                                toward you                                
                                                during the                                
                                                interview?                                

                                                               1\. Not at all             
                                                               attentive                  

                                                               2\. Somewhat               
                                                               attentive                  

                                                               3\. Very                   
                                                               attentive                  

  7\.             (IQUESTION)   How much                                                  
                                difficulty do                                             
                                you think the                                             
                                respondent had                                            
                                in                                                        
                                understanding                                             
                                most of the                                               
                                question?                                                 

                                                               1\. A lot of               
                                                               difficulty                 

                                                               2\. Some                   
                                                               difficulty                 

                                                               3\. No difficulty          
  --------------- ------------- --------------- -------------- ----------------- -------- ------------------------------------------------------------

+-----+---------------------+---------------------+---------------------+
| **Y |                     |                     |                     |
| OUR |                     |                     |                     |
| [H  |                     |                     |                     |
| OUS |                     |                     |                     |
| EHO |                     |                     |                     |
| LD] |                     |                     |                     |
| {.u |                     |                     |                     |
| nde |                     |                     |                     |
| rli |                     |                     |                     |
| ne} |                     |                     |                     |
| INC |                     |                     |                     |
| OME |                     |                     |                     |
| ^1  |                     |                     |                     |
| ^** |                     |                     |                     |
+-----+---------------------+---------------------+---------------------+
|     | ### Approximate     | ### Approximate     | ### Approximate     |
|     |                     |                     |                     |
|     | # WEEKLY            | **MONTHLY**         | **ANNUAL**          |
|     |                     |                     |                     |
|     | ## In Pesos         | **In Pesos**        | **In Pesos**        |
+-----+---------------------+---------------------+---------------------+
| ##  | Less than P2600     | Less than P9750     | Less than P117000   |
| # J |                     |                     |                     |
+-----+---------------------+---------------------+---------------------+
| ##  | P2600 to under      | P9750 to under      | P117000 to under    |
| # R | P4500               | P19500              | P234000             |
+-----+---------------------+---------------------+---------------------+
| ##  | P4500 to under      | P19500 to under     | P234000 to under    |
| # C | P7800               | P32500              | P390000             |
+-----+---------------------+---------------------+---------------------+
| ##  | P7800 to under      | P32500 to under     | P390000 to under    |
| # M | P14950              | P65000              | P780000             |
+-----+---------------------+---------------------+---------------------+
| ##  | P14950 to under     | P65000 to under     | P780000 to under    |
| # F | P22750              | P97500              | P1170000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P22750 to under     | P97500 to under     | P1170000 to under   |
| # S | P29900              | P130000             | P1560000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P29900 to under     | P130000 to under    | P1560000 to under   |
| # K | P37700              | P162500             | P1950000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P37700 to under     | P162500 to under    | P1950000 to under   |
| # P | P44850              | P195000             | P2340000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P448500 to under    | P195000 to under    | P2340000 to under   |
| # D | P74750              | P325000             | P3900000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P74750 to under     | P325000 to under    | P3900000 to under   |
| # H | P112450             | P487500             | P5850000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P112450 to under    | P487500 to under    | P5850000 to under   |
| # U | P150150             | P650000             | P7800000            |
+-----+---------------------+---------------------+---------------------+
| ##  | P150150 or more     | P650000 or more     | P7800000 or more    |
| # N |                     |                     |                     |
+-----+---------------------+---------------------+---------------------+

^1^ Exchange rate as of February 2006 is P65 = €1

***Instructions to the respondent:***

Salamat po sa iyong pahintulot na kayo ay aming makapanayam. Ang layunin
ng proyekto na ito ay upang makabuo ng mga tanong tungkol sa kalusugan
at kakayahan ng mga tao na gawin ang mga gawain. Ang mga tanong na
mabubuo ay itatanong sa mga tao na may iba't ibang edad sa buong mundo.
Sa proyektong ito, nais naming malaman kung ang aming pagtatanong ay may
kabuluhan sa inyo at kung magkapareho ang pagkakaintindi ng mga taong
sumagot sa aming mga katanungan. Ang pakikipanayam naming sa inyo ay
makapagbibigay sa amin ng malaking tulong malaman kung ang mga tanong ay
tama.

Ang panayam na ito ay aabot ng isang oras. Ito ay tungkol sa inyong
kakayahan na gawin ang inyong mga gawain. Marami sa mga tanong ay parang
paulit-ulit lang o kaya'y kakaiba o personal. Ito ay dahil sinusuri
namin ang mga tanong at kailangan naming malaman kung ano ang karaniwang
iniisip ng mga tao sa pagbuo ng kani-kanilang kasagutan. Pakisagot po
ang mga tanong ng ayon sa inyong pagkakaintindi at sa abot ng inyong
makakaya.

Ang lahat po ng inyong sagot ay konpidensiyal at gagamitin lamang sa
pag-aaral. Kung ayaw po ninyong sagutin ang ilang mga katanungan,
magsabi lang po kayo at tayo ay magpapatuloy sa susunod na katanungan.
Bago po tayo magsimula, mayroon po ba kayong tanong?