**APPENDIX 2**

**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         |   |                                |
|      |                           |   | day month year                 |
|      | c\) TIME INTERVIEW ENDED  |   |                                |
|      |                           |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
|      | d\) TOTAL DURATION        |   | >                              |
|      |                           |   | > hrs min                      |
|      |                           |   | >                              |
|      |                           |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
|      |                           |   | >                              |
|      |                           |   | > hrs min                      |
|      |                           |   | >                              |
|      |                           |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
|      |                           |   | >                              |
|      |                           |   | > hrs min                      |
+------+---------------------------+---+--------------------------------+
| #    | LANGUAGE                  |   | Filipino 1                     |
| # F4 |                           |   |                                |
|      |                           |   | English 2                      |
|      |                           |   |                                |
|      |                           |   | Others 3                       |
|      |                           |   |                                |
|      |                           |   | (pls specify)                  |
|      |                           |   | \_                             |
|      |                           |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+------+---------------------------+---+--------------------------------+
| ##   | ## COUNTRY                |   | **[Philippines]{.underline}**  |
|      |                           |   |                                |
| #    |                           |   |                                |
| # F5 |                           |   |                                |
+------+---------------------------+---+--------------------------------+
| **I  |                           | * |                                |
| NTER |                           | * |                                |
| VIEW |                           | S |                                |
| ER'S |                           | U |                                |
| NAM  |                           | P |                                |
| E:** |                           | E |                                |
|      |                           | R |                                |
|      |                           | V |                                |
|      |                           | I |                                |
|      |                           | O |                                |
|      |                           | R |                                |
|      |                           | ' |                                |
|      |                           | S |                                |
|      |                           | N |                                |
|      |                           | A |                                |
|      |                           | M |                                |
|      |                           | E |                                |
|      |                           | : |                                |
|      |                           | * |                                |
|      |                           | * |                                |
+------+---------------------------+---+--------------------------------+

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 13%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 18%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 13%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><strong>SECTION 2. Demographic and Background
Information</strong></td>
</tr>
<tr class="even">
<td><p id="section-1" class="heading"></p></td>
<td colspan="10"><em>RECORD SEX AS OBSERVED</em></td>
<td colspan="3"><p>Female 1</p>
<p>Male 2</p></td>
</tr>
<tr class="odd">
<td><strong>1</strong></td>
<td colspan="10">Ilang taon na kayo sa kasalukuyan?</td>
<td colspan="3">___/___ years</td>
</tr>
<tr class="even">
<td><strong>2</strong></td>
<td colspan="10"><p>Sa kabuuan, ilang taon ang inyong ginugol sa
pag-aaral</p>
<p>sa eskuwelahan, kolehiyo o unibersidad?</p></td>
<td colspan="3">___/___ 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="5"><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="3"><p>4 Estudyante</p>
<p>5 Gumaganap ng gawaing 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="4"><p>1 Married</p>
<p>2 Widowed</p></td>
<td colspan="4"><p>3 Divorced</p>
<p>4 Separated</p></td>
<td colspan="2"><p>5 Never married</p>
<p>6 Living with partner</p></td>
<td colspan="4"><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 colspan="2"><p>J</p>
<p>R</p>
<p>C</p>
<p>M F</p></td>
<td colspan="2"></td>
<td colspan="2"><p>S</p>
<p>K</p>
<p>P D H</p></td>
<td colspan="2"></td>
<td colspan="3"><p>U</p>
<p>N</p>
<p>D</p>
<p>DK</p></td>
<td colspan="2"></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="13"><strong>NAME</strong></td>
<td><strong>AGE</strong></td>
</tr>
<tr class="odd">
<td colspan="2">1</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">2</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">3</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">4</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">5</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">6</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">7</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">8</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">9</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">10</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">11</td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">12</td>
<td colspan="11"></td>
<td></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>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 19%" />
<col style="width: 4%" />
<col style="width: 20%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="16"><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="3">1.</td>
<td colspan="2">(VSVISION)</td>
<td colspan="11"><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="16"></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="5"></td>
<td colspan="3"></td>
<td colspan="8">Hindi, walang hirap (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Oo, kaunting hirap (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Oo, sobrang hirap (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Hindi kayang gawin (3)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="16">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="4">(VSREPE)</td>
<td colspan="5">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="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="4">(VSOPT)</td>
<td colspan="5">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="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="4">(VSCLARI)</td>
<td colspan="5">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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="5"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(VSWHY)</td>
<td colspan="11">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(VSGLASS)</td>
<td colspan="11">Kayo ba ay palaging gumagamit ng salamin o sa tuwing
may ginagawa ka lamang o hindi ka gumagamit ng salamin?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"></td>
<td colspan="3"></td>
<td>Sa lahat ng oras (2)</td>
<td></td>
<td>Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="3">Hindi gumagamit (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>3 – 4 Only if respondent reported any
difficulty seeing:</strong></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="2">3.</td>
<td colspan="3">(VSDIFF)</td>
<td colspan="11">[Kapag wala kang suot na salamin], gaano ka kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="16"><strong>Glasses wearers only:</strong></td>
</tr>
<tr class="odd">
<td colspan="4">3a.</td>
<td colspan="2">(VSDIFFG)</td>
<td colspan="10">Kapag nakasuot ka na ng salamin, gaano ka kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"><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)
  --------- ------------- ---------- ------------- -------------- ------------- -------------- --- ------------------------------------------

### VISION --PROXY-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 19%" />
<col style="width: 4%" />
<col style="width: 20%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="16"><strong>Ang mga sumusunod na katanungan ay tungkol sa
kahirapan na nararanasan sa paggawa ng mga gawain dahil sa SULIRANIN SA
KALUSUGAN.</strong></td>
</tr>
<tr class="even">
<td colspan="3">1.</td>
<td colspan="2">(VPVISION)</td>
<td colspan="11"><h2
id="si-pangalan-ba-ay-may-kahirapan-sa-paningin-kahit-na-siya-ay-gumagamit-na-ng-salamin-sa-mata">Si
(PANGALAN) ba ay may kahirapan sa paningin, kahit na siya ay gumagamit
na ng salamin sa mata?</h2></td>
</tr>
<tr class="odd">
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="5"></td>
<td colspan="3"></td>
<td colspan="8">Hindi, walang hirap (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Oo, kaunting hirap (1)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Oo, sobrang hirap (2)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Hindi kayang gawin (3)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="16">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="4">(VPREPE)</td>
<td colspan="5">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="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="4">(VPOPT)</td>
<td colspan="5">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="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="4">(VPCLARI)</td>
<td colspan="5">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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="5"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(VPWHY)</td>
<td colspan="11">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(VPGLASS)</td>
<td colspan="11">Si (PANGALAN) ba ay palaging gumagamit ng salamin o sa
tuwing may ginagawa lamang o hindi gumagamit ng salamin?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"></td>
<td colspan="3"></td>
<td>Sa lahat ng oras (2)</td>
<td></td>
<td>Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="3">Hindi gumagamit (0)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>3 – 4 Only if respondent reported any
difficulty seeing:</strong></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="3">(VPDIFF)</td>
<td colspan="11">[Kapag wala siyang suot na salamin], gaano siya kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="16"><strong>Glasses wearers only:</strong></td>
</tr>
<tr class="even">
<td colspan="4">3a.</td>
<td colspan="2">(VPDIFFG)</td>
<td colspan="10">Kapag nakasuot na siya ng salamin, gaano siya kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----------------------- ---------- ---------- -------------- ------------ ------------- ------------- -------- --- ------------------------
  4\.                     (VPEFF)               \[Kapag wala                                                         
                                                siyang suot na                                                       
                                                salamin\], sa                                                        
                                                tuwing si                                                            
                                                (PANGALAN) ay                                                        
                                                nahihirapang                                                         
                                                tumingin,                                                            
                                                gaano ang                                                            
                                                kanyang                                                              
                                                ginagawang                                                           
                                                pagsisikap                                                           
                                                upang makakita                                                       
                                                nang maayos?                                                         

                                                                            Walang                                   
                                                                            pagsisikap                               
                                                                            (0)                                      

                                                                            Kaunting                                 
                                                                            pagsisikap                               
                                                                            (1)                                      

                                                                            Sobrang                                  
                                                                            pagsisikap                               
                                                                            (2)                                      

                                                                            *Walang                                  
                                                                            sagot/hindi                              
                                                                            alam* (9)                                

  **Glasses wearers                                                                                                  
  only:**                                                                                                            

  4a.                                (VPEFFG)                  Kapag                                                 
                                                               nakasuot na                                           
                                                               siya ng                                               
                                                               salamin,                                              
                                                               gaano ang                                             
                                                               kanyang                                               
                                                               ginagawang                                            
                                                               pagsisikap                                            
                                                               upang                                                 
                                                               makakita                                              
                                                               nang maayos?                                          

                                                                            Walang                                   
                                                                            pagsisikap                               
                                                                            (0)                                      

                                                                            Kaunting                                 
                                                                            pagsisikap                               
                                                                            (1)                                      

                                                                            Sobrang                                  
                                                                            pagsisikap                               
                                                                            (2)                                      

                                                                            *Walang                                  
                                                                            sagot/hindi                              
                                                                            alam* (9)                                

                                                                                                                     

  [ASK                                                                                                               
  EVERYONE]{.underline}                                                                                              

  5\.                     (VPACT)               Mayroon bang                                                         
                                                mga gawain na                                                        
                                                hindi na                                                             
                                                magawa ni                                                            
                                                (PANGALAN)                                                           
                                                dahil sa                                                             
                                                problema sa                                                          
                                                kanyang                                                              
                                                paningin?                                                            

                                                                            Wala (1)                                 

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

                                                                            *Walang                                  
                                                                            sagot/hindi                              
                                                                            alam* (9)                                

                                                                                                                     

                                                                            5a.           (VPACTOPEN)   Anong        
                                                                                                        gawain       
                                                                                                        iyon?        

                                                                                                                     

  6\.                     (VPWORR)              Gaano ka                                                             
                                                nag-aalala o                                                         
                                                nababahala sa                                                        
                                                paningin ni                                                          
                                                (PANGALAN)?                                                          

                                                                            Hindi                                    
                                                                            nag-aalala                               
                                                                            (0)                                      

                                                                            Bahagyang                                
                                                                            nag-aalala                               
                                                                            (1)                                      

                                                                            Sobrang                                  
                                                                            nag-aalala                               
                                                                            (2)                                      

                                                                            *Walang                                  
                                                                            sagot/hindi                              
                                                                            alam* (9)                                

                                                                                                                     

  7\.                     (VPCOND)              May                                                                  
                                                nakapagsabi na                                                       
                                                ba kay                                                               
                                                (PANGALAN) na                                                        
                                                dalubhasa sa                                                         
                                                kalusugan na                                                         
                                                mayroon siyang                                                       
                                                pinsala o                                                            
                                                sakit (katulad                                                       
                                                ng katarata o                                                        
                                                glaucoma) na                                                         
                                                nakakaapekto                                                         
                                                sa kanyang                                                           
                                                paningin?                                                            

                                                                            Oo (1)                                   Wala (0)

                                                                            *Walang                                  
                                                                            sagot/hindi                              
                                                                            alam* (9)                                

                                                                                                                     

  8\.                     (VPTEST)              Sa nakalipas                                                         
                                                na dalawang                                                          
                                                taon,                                                                
                                                naipasuri ba                                                         
                                                ni (PANGALAN)                                                        
                                                ang kanyang                                                          
                                                paningin?                                                            

                                                                            Oo (1)                                   Hindi (0)

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

  --------- ------------- ---------- --------- ------------- -------------- ----------- ------------- -------------- ------------------------------------------
  9\.       \[Kapag wala                                                                                             
            siyang suot                                                                                              
            na salamin\],                                                                                            
            Si (PANGALAN)                                                                                            
            ba ay may                                                                                                
            kahirapang. .                                                                                            
            .                                                                                                        

  a\.                     (VPNEAR)                           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\.                                (VPFAR)                 Tumingin at                                             
                                                             makakilala ng                                           
                                                             isang tao na                                            
                                                             dati na niyang                                          
                                                             kakilala na                                             
                                                             nasa pitong                                             
                                                             metro                                                   
                                                             (dalawampung                                            
                                                             talampakan)                                             
                                                             ang layo mula                                           
                                                             sa kanya?                                               

                                                                                        Hindi                        
                                                                                        nahihirapan                  
                                                                                        (0)                          

                                                                                        Bahagyang                    
                                                                                        nahihirapan                  
                                                                                        (1)                          

                                                                                        Sobrang                      
                                                                                        nahihirapan                  
                                                                                        (2)                          

                                                                                        Hindi kayang                 
                                                                                        gawin (3)                    

                                                                                        *Walang                      
                                                                                        sagot/hindi                  
                                                                                        alam* (9)                    

                                                                                                                     

  Glasses                                                                                                            
  wearers                                                                                                            
  only:                                                                                                              

                                               9a. \[Kapag                                                           
                                               nakasuot na                                                           
                                               siya ng                                                               
                                               salamin                                                               
                                               siya\], Si                                                            
                                               (PANGALAN) ba                                                         
                                               may ay                                                                
                                               kahirapang. .                                                         
                                               .                                                                     

  a\.                                                                       (VPNEARG)                 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\.                                                                       (VPFARG)                  Tumingin at    
                                                                                                      makakilala ng  
                                                                                                      isang tao na   
                                                                                                      dati na niyang 
                                                                                                      kakilala na    
                                                                                                      nasa pitong    
                                                                                                      metro          
                                                                                                      (dalawampung   
                                                                                                      talampakan)    
                                                                                                      ang layo mula  
                                                                                                      sa kanya?      

                                                                                                                     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: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 21%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(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="16"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="16">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="3">(HSREPE)</td>
<td colspan="6">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="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="3">(HSOPT)</td>
<td colspan="6">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="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="3">(HSCLARI)</td>
<td colspan="6">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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="6"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(HSWHY)</td>
<td colspan="11">Bakit ninyo nasabi yon?</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(HSAID)</td>
<td colspan="11">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>Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="3">Hindi gumagamit (0)</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="16"></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>3 – 4 Only if respondent reported any
difficulty hearing:</strong></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="2">3.</td>
<td colspan="3">(HSDIFF)</td>
<td colspan="11">[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="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>
<tr class="even">
<td colspan="16"><strong>Hearing aid users only:</strong></td>
</tr>
<tr class="odd">
<td colspan="4">3a.</td>
<td colspan="2">(HSDIFFA)</td>
<td colspan="10">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="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8"><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)                                                                                 
  --------- -------------- ----------- ----------- ------------ ------------- ------------ --------- ------------- ------------- --------- --------- ------------- --- -------- --- ------- -- ---------------

### HEARING---PROXY-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 21%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(HPHEAR)</td>
<td colspan="11"><h2
id="si-pangalan-ba-ay-may-kahirapan-sa-pandinig-kahit-na-siya-ay-gumagamit-na-ng-hearing-aid">Si
(PANGALAN) ba ay may kahirapan sa pandinig, kahit na siya ay gumagamit
na ng “hearing aid”?</h2></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="16">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="3">(HPREPE)</td>
<td colspan="6">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="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="3">(HPOPT)</td>
<td colspan="6">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="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="3">(HPCLARI)</td>
<td colspan="6">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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="6"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td colspan="2">(HPWHY)</td>
<td colspan="11">Bakit ninyo nasabi yon?</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td colspan="2">(HPAID)</td>
<td colspan="11">Si (PANGALAN) ba ay palaging gumagamit ng “hearing aid”
o sa tuwing may ginagawa lamang o hindi 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>Sa tuwing may ginagawa lamang (1)</td>
<td colspan="2"></td>
<td colspan="3">Hindi gumagamit (0)</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="16"></td>
</tr>
<tr class="odd">
<td colspan="16"><strong>3 – 4 Only if respondent reported any
difficulty hearing:</strong></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="3">(HPDIFF)</td>
<td colspan="11">[Kapag wala siyang “hearing aid”], gaano siya kadalas
nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="9">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="16"><strong>Hearing aid users only:</strong></td>
</tr>
<tr class="even">
<td colspan="4">3a.</td>
<td colspan="2">(HPDIFFA)</td>
<td colspan="10">Kapag gumagamit na siya ng “hearing aid”, gaano siya
kadalas nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="6" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----------------------- ---------- ---------- --------------- ------------- ------------- ---------- -- ---------------------
  4\.                     (HPEFF)               \[Kapag wala                                              
                                                siyang "hearing                                           
                                                aid"\], sa                                                
                                                tuwing si                                                 
                                                (PANGALAN) ay                                             
                                                nahihirapang                                              
                                                makarinig,                                                
                                                gaano ang                                                 
                                                kanyang                                                   
                                                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.                                (HPEFFA)   Kapag gumagamit                                           
                                                na siya ng                                                
                                                "hearing aid",                                            
                                                gaano ang                                                 
                                                kanyang                                                   
                                                ginagawang                                                
                                                pagsisikap                                                
                                                upang makarinig                                           
                                                nang maayos?                                              

                                                                Walang                                    
                                                                pagsisikap                                
                                                                (0)                                       

                                                                Kaunting                                  
                                                                pagsisikap                                
                                                                (1)                                       

                                                                Sobrang                                   
                                                                pagsisikap                                
                                                                (2)                                       

                                                                *Walang                                   
                                                                sagot/hindi                               
                                                                alam* (9)                                 

                                                                                                          

  [ASK                                                                                                    
  EVERYONE]{.underline}                                                                                   

  5\.                     (HPACT)               Mayroon bang                                              
                                                mga gawain na                                             
                                                hindi na magawa                                           
                                                ni (PANGALAN)                                             
                                                dahil sa                                                  
                                                problema sa                                               
                                                kanyang                                                   
                                                pandinig?                                                 

                                                                Wala (1)                                  

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

                                                                *Walang                                   
                                                                sagot/hindi                               
                                                                alam* (9)                                 

                                                                                                          

                                                                5a.           (HPACTOPEN)   Anong         
                                                                                            gawain        
                                                                                            iyon?         

                                                                                                          

  6\.                     (HPWORR)              Gaano ka                                                  
                                                nag-aalala o                                              
                                                nababahala sa                                             
                                                pandinig ni                                               
                                                (PANGALAN)?                                               

                                                                Hindi                                     
                                                                nag-aalala                                
                                                                (0)                                       

                                                                Bahagyang                                 
                                                                nag-aalala                                
                                                                (1)                                       

                                                                Sobrang                                   
                                                                nag-aalala                                
                                                                (2)                                       

                                                                *Walang                                   
                                                                sagot/hindi                               
                                                                alam* (9)                                 

                                                                                                          

  7\.                     (HPLOSS)              May nakapagsabi                                           
                                                na ba kay                                                 
                                                (PANGALAN) na                                             
                                                dalubhasa sa                                              
                                                kalusugan na                                              
                                                nawawalan siya                                            
                                                ng pandinig?                                              

                                                                Oo (1)                                    Wala (2)

                                                                *Walang                                   
                                                                sagot/hindi                               
                                                                alam* (9)                                 

                                                                                                          

  8\.                     (HPTEST)              Sa nakalipas na                                           
                                                dalawang taon,                                            
                                                si (PANGALAN)                                             
                                                ba ay                                                     
                                                nakapagpasuri                                             
                                                na upang                                                  
                                                malaman kung                                              
                                                siya ay                                                   
                                                nakakarinig                                               
                                                nang maayos?                                              

                                                                Oo (1)                                    Hindi (2)

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

  --------- ------------------ ----------- ----------- ---------------- ------------- ------------ --------- ------------- ------------- --------- --------- ------------- --- -------- --- ------- -- ---------------
  9\.       \[Kapag wala                                                                                                                                                                               
            siyang "hearing                                                                                                                                                                            
            aid",\] Si                                                                                                                                                                                 
            (PANGALAN) ba ay                                                                                                                                                                           
            may kahirapang                                                                                                                                                                             
            makarinig ng                                                                                                                                                                               
            pinag-uusapan...                                                                                                                                                                           

  a\.                          (HPCROWD)                                                           Sa isang                                                                                            
                                                                                                   mataong                                                                                             
                                                                                                   silid?                                                                                              

                                                                                                                           Hindi                                                                       
                                                                                                                           nahihirapan                                                                 
                                                                                                                           (0)                                                                         

                                                                                                                           Bahagyang                                                                   
                                                                                                                           nahihirapan                                                                 
                                                                                                                           (1)                                                                         

                                                                                                                           Sobrang                                                                     
                                                                                                                           nahihirapan                                                                 
                                                                                                                           (2)                                                                         

                                                                                                                           Hindi kayang                                                                
                                                                                                                           gawin (3)                                                                   

                                                                                                                           *Walang                                                                     
                                                                                                                           sagot/hindi                                                                 
                                                                                                                           alam* (9)                                                                   

                                                                                                                                                                                                       

  b\.                                      (HPQUIET)                                               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 na                                                                                                                                    
                                                       siya ng "hearing                                                                                                                                
                                                       aid", si                                                                                                                                        
                                                       (PANGALAN) ba ay                                                                                                                                
                                                       may kahirapang                                                                                                                                  
                                                       makarinig ng                                                                                                                                    
                                                       pinag-uusapan. .                                                                                                                                

  a\.                                                                                 (HPCROWDA)                                                   Sa isang                                            
                                                                                                                                                   mataong                                             
                                                                                                                                                   silid?                                              

                                                                                                                                                             Hindi                                     
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (0)                                       

                                                                                                                                                             Bahagyang                                 
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (1)                                       

                                                                                                                                                             Sobrang                                   
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (2)                                       

                                                                                                                                                             Hindi kayang                              
                                                                                                                                                             gawin (3)                                 

                                                                                                                                                             *Walang                                   
                                                                                                                                                             sagot/hindi                               
                                                                                                                                                             alam* (9)                                 

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

                                                                                                                                                             Hindi                                     
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (0)                                       

                                                                                                                                                             Bahagyang                                 
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (1)                                       

                                                                                                                                                             Sobrang                                   
                                                                                                                                                             nahihirapan                               
                                                                                                                                                             (2)                                       

                                                                                                                                                             Hindi kayang                              
                                                                                                                                                             gawin (3)                                 

                                                                                                                                                             *Walang                                   
                                                                                                                                                             sagot/hindi                               
                                                                                                                                                             alam* (9)                                 

                                                                                                                                                                                                       

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

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

                                                                                                             *Walang                                                                                   
                                                                                                             sagot/hindi                                                                               
                                                                                                             alam* (9)                                                                                 

  11\.      (HPPROB)                                                    Madalas bang                                                                                                                   
                                                                        sinasabihan                                                                                                                    
                                                                        siya ng                                                                                                                        
                                                                        inyong                                                                                                                         
                                                                        kapamilya o                                                                                                                    
                                                                        kasambahay na                                                                                                                  
                                                                        may suliranin                                                                                                                  
                                                                        o problema                                                                                                                     
                                                                        siya 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: 14%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 20%" />
<col style="width: 3%" />
<col style="width: 23%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">3.</td>
<td>(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="15"></td>
</tr>
<tr class="odd">
<td colspan="4" 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="4"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="15">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="2">(CSREPE)</td>
<td colspan="4">Need you to <u>repeat</u> any part of the question?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="2">(CSOPT)</td>
<td colspan="4">Have any difficulty using the <u>response
options</u>?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="2">(CSCLARI)</td>
<td colspan="4">ask for <u>clarification</u> or qualify their
answer?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(CSWHY)</td>
<td colspan="11">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>2 – 5 Only if respondent reported any
difficulty remembering or concentrating:</strong></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="2">2.</td>
<td colspan="2">(CSREMCON)</td>
<td colspan="11">Kayo ba ay may kahirapang makaalala o mag-concentrate
(magtuon ng pansin) o pareho?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="2"></td>
<td colspan="2"></td>
<td>Makaalala (remembering) (1)</td>
<td></td>
<td colspan="2">Mag-concentrate (magtuon ng pansin) (2)</td>
<td colspan="2"></td>
<td colspan="3">Pareho (both) (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="15"></td>
</tr>
<tr class="odd">
<td colspan="2">3<strong>.</strong></td>
<td colspan="2">(CSDIFF)</td>
<td colspan="11">Gaano ka kadalas nahihirapang makaalala o
mag-concentrate (magtuon ng pansin) nang maayos?</td>
</tr>
<tr class="even">
<td colspan="4" 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>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="2">4.</td>
<td colspan="2">(CSEFF)</td>
<td colspan="11">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="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="9">Walang pagsisiskap (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Kaunting pagsisikap (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Sobrang pagsisikap (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 27%" />
</colgroup>
<tbody>
<tr class="odd">
<td>5.</td>
<td colspan="2">(CSCAUSE)</td>
<td colspan="10"><p>Kayo ba ay naniniwala na ang iyong kahirapang
makaalala o makapag-concentrate (makapagtuon ng pansin) ay…</p>
<p>[MARK ALL THAT APPLY]</p></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td></td>
<td colspan="8">dahil sa marami kang ginagawa? (1)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">dahil sa iyong pagtanda? (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">o dahil sa iba pang kadahilanan? (3)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="13"><u>ASK EVERYONE</u></td>
</tr>
<tr class="even">
<td>6.</td>
<td colspan="2">(CSACT)</td>
<td colspan="10">Mayroon bang mga gawain na hindi mo magawa dahil sa
problema mong makaalala o makapag-concentrate (makapagtuon ng
pansin)?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="3"></td>
<td></td>
<td colspan="8">Wala (1)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">Mayroon (2) (Go to 6a. CSACTOPEN)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2">6a.</td>
<td colspan="2">(CSACTOPEN)</td>
<td colspan="4">Anong gawain iyon?</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td>7.</td>
<td colspan="2">(CSWORR)</td>
<td colspan="10">Gaano ka nag-aalala o nababahala sa iyong kakayahang
makaalala o makapag-concentrate (magtuon ng pansin)?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td></td>
<td colspan="8">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">Sobrang nag-aalala (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td>8.</td>
<td colspan="12">Kayo ba ay may kahirapan. . .</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="2">a.</td>
<td colspan="4">(CSNAMES)</td>
<td colspan="7">Sa pag-alala ng mga pangalan ng tao o lugar?</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2">b.</td>
<td colspan="4">(CSAPPT)</td>
<td colspan="7">Sa pag-alala ng pinagkasunduang pagkikita
(appointments)?</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="2">c.</td>
<td colspan="4">(CSPLACES)</td>
<td colspan="7">Sa pag-alala kung paano makarating sa pamilyar na
lugar?</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2">d.</td>
<td colspan="4">(CSTASKS)</td>
<td colspan="7">Sa pag-alala ng mga mahahalagang gawain, gaya ng
pag-inom ng gamot o pagbabayad ng mga bayarin?</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ------ ------------ --------------------- --------------------------------------------------
  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)
  ------ ------------ --------------------- --------------------------------------------------

### COGNITIVE---PROXY-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 15%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 20%" />
<col style="width: 3%" />
<col style="width: 23%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">3.</td>
<td>(CPCOG)</td>
<td colspan="11"><h2
id="si-pangalan-ba-ay-may-kahirapang-makaalala-o-mag-concentrate-magtuon-ng-pansin">Si
(PANGALAN) ba ay may kahirapang makaalala o mag-concentrate (magtuon ng
pansin)?</h2></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="4" 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="4"></td>
<td colspan="2"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="15">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="2">(CPREPE)</td>
<td colspan="4">Need you to <u>repeat</u> any part of the question?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="2">(CPOPT)</td>
<td colspan="4">Have any difficulty using the <u>response
options</u>?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="2">(CPCLARI)</td>
<td colspan="4">ask for <u>clarification</u> or qualify their
answer?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(CPWHY)</td>
<td colspan="11">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>2 – 5 Only if respondent reported any
difficulty remembering or concentrating:</strong></td>
</tr>
<tr class="even">
<td colspan="2">2.</td>
<td colspan="2">(CPREMCON)</td>
<td colspan="11">Si (PANGALAN) ba ay may kahirapang makaalala o
makapag-concentrate (makapagtuon ng pansin) o pareho?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"></td>
<td colspan="2"></td>
<td>Makaalala (remembering) (1)</td>
<td></td>
<td colspan="2">Makapag-concentrate (makapagtuon ng pansin)(2)</td>
<td colspan="2"></td>
<td colspan="3">Pareho (both) (3)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="2">3<strong>.</strong></td>
<td colspan="2">(CPDIFF)</td>
<td colspan="11">Gaano siya kadalas nahihirapang makaalala o
mag-concentrate (magtuon ng pansin) nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="9">Hindi nahihirapan(0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="2">(CPEFF)</td>
<td colspan="11">Sa tuwing si (PANGALAN) ay nahihirapan, gaano ang
kanyang ginagawang pagsisikap upang makaalala o makapag-concentrate
(makapagtuon ng pansin) nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="9">Walang pagsisiskap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Kaunting pagsisikap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Sobrang pagsisikap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 10%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 27%" />
</colgroup>
<tbody>
<tr class="odd">
<td>5.</td>
<td colspan="2">(CPCAUSE)</td>
<td colspan="10"><p>Si (PANGALAN) ba ay naniniwala na ang kanyang
kahirapang makaalala o makapag-concentrate (makapagtuon ng pansin)
ay…</p>
<p>[MARK ALL THAT APPLY]</p></td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td></td>
<td colspan="8">dahil sa marami siyang ginagawa? (1)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">dahil sa kanyang pagtanda? (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">o dahil sa iba pang kadahilanan? (3)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="13"><u>ASK EVERYONE</u></td>
</tr>
<tr class="even">
<td>6.</td>
<td colspan="2">(CPACT)</td>
<td colspan="10">Mayroon bang mga gawain na hindi na magawa ni
(PANGALAN) dahil sa kanyang problemang makaalala o makapag-concentrate
(makapagtuon ng pansin)?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="3"></td>
<td></td>
<td colspan="8">Wala (1)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">Mayroon (2) (Go to 6a. CSACTOPEN)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2">6a.</td>
<td colspan="2">(CPACTOPEN)</td>
<td colspan="4">Anong gawain iyon?</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td>7.</td>
<td colspan="2">(CPWORR)</td>
<td colspan="10">Gaano ka nag-aalala o nababahala sa kakayahang
makaalala o makapag-concentrate (magtuon ng pansin) ni (PANGALAN)?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td></td>
<td colspan="8">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">Sobrang nag-aalala (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td>8.</td>
<td colspan="12">Si (PANGALAN) ay may kahirapan. . .</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="2">a.</td>
<td colspan="4">(CPNAMES)</td>
<td colspan="7">Sa pag-alala ng mga pangalan ng tao o lugar?</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2">b.</td>
<td colspan="4">(CPAPPT)</td>
<td colspan="7">Sa pag-alala ng pinagkasunduang pagkikita
(appointments)?</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="2">c.</td>
<td colspan="4">(CPPLACES)</td>
<td colspan="7">Sa pag-alala kung paano makarating sa pamilyar na
lugar?</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2">d.</td>
<td colspan="4">(CPTASKS)</td>
<td colspan="7">Sa pag-alala ng mga mahahalagang gawain, gaya ng
pag-inom ng gamot o pagbabayad ng mga bayarin?</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="2"></td>
<td>Oo (1)</td>
<td></td>
<td>Hindi (2)</td>
<td></td>
<td><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ------ ------------ --------------------- --------------------------------------------------
  9\.    (CPTEN)      Si (PANGALAN) 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\.   (CPNEW)      Si (PANGALAN) 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\.   (CPSOLUT)    Si (PANGALAN) ba ay   
                      may kahirapang        
                      makahanap ng solusyon 
                      sa mga problema sa    
                      pang-araw-araw niyang 
                      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: 18%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 19%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">4.</td>
<td>(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="17"></td>
</tr>
<tr class="odd">
<td colspan="4" 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="4"></td>
<td colspan="2"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="17">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="2">(MSREPE)</td>
<td colspan="6">need you to <u>repeat</u> any part of the question?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="2">(MSOPT)</td>
<td colspan="6">have any difficulty using the <u>response
options</u>?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="2">(MSCLARI)</td>
<td colspan="6">ask for <u>clarification</u> or qualify their
answer?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(MSWHY)</td>
<td colspan="13">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td>(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="4" 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="17"></td>
</tr>
<tr class="even">
<td colspan="4">2a.</td>
<td colspan="4">(MSAIDTYPE)</td>
<td colspan="9">Anong kagamitan ang ginagamit mo?</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="17"><strong>3 – 5 Only if respondent reported any
difficulty walking or climbing steps:</strong></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="2">(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="4" rowspan="2"></td>
<td colspan="3"></td>
<td colspan="2">Paglalakad (1)</td>
<td></td>
<td colspan="2">Pag-akyat (2)</td>
<td colspan="2"></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="17"></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="2">(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="4" 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)                    
  ------ ------------------ ------------- ------------ ------------- ----------- ------------------ --- -------------------

### LOWER MOBILITY---PROXY-REPORT

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 16%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 21%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">4.</td>
<td>(MPWALK)</td>
<td colspan="13"><h2
id="si-pangalan-ba-ay-may-kahirapan-sa-paglalakad-o-pag-akyat-sa-hagdan">Si
(PANGALAN) ba ay may kahirapan sa paglalakad o pag-akyat sa
hagdan?</h2></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="4" 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="4"></td>
<td colspan="2"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="17">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="2">(MPREPE)</td>
<td colspan="6">need you to <u>repeat</u> any part of the question?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="2">(MPOPT)</td>
<td colspan="6">have any difficulty using the <u>response
options</u>?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="2">(MPCLARI)</td>
<td colspan="6">ask for <u>clarification</u> or qualify their
answer?</td>
<td colspan="2"></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(MPWHY)</td>
<td colspan="13">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="3">2.</td>
<td>(MPAID)</td>
<td colspan="13">Si (PANGALAN) ba ay gumagamit ng mga kagamitan katulad
ng wheelchair, panggabay sa paglakad o tungkod upang makatulung sa
kanyang pagkilos?</td>
</tr>
<tr class="even">
<td colspan="4" 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="17"></td>
</tr>
<tr class="even">
<td colspan="4">2a.</td>
<td colspan="4">(MSAIDTYPE)</td>
<td colspan="9">Anong kagamitan ang ginagamit mo?</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="17"><strong>3 – 5 Only if respondent reported any
difficulty walking or climbing steps:</strong></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="2">3.</td>
<td colspan="2">(MPWALKSTEP)</td>
<td colspan="13">Si (PANGALAN) ba ay may kahirapan sa paglalakad o
pag-akyat sa hagdan o pareho?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"></td>
<td colspan="3"></td>
<td colspan="2">Paglalakad (1)</td>
<td></td>
<td colspan="2">Pag-akyat (2)</td>
<td colspan="2"></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="17"></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="2">(MPDIFF)</td>
<td colspan="13">[Kapag wala siyang kagamitan, ….] Gaano siya kadalas
nahihirapang maglakad o umakyat sa hagdan?</td>
</tr>
<tr class="odd">
<td colspan="4" 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.                                                (MPDIFFA)                                Kapag gamit na          
                                                                                              niya ang                
                                                                                              kanyang                 
                                                                                              kagamitan,              
                                                                                              gaano siya              
                                                                                              kadalas                 
                                                                                              nahihirapang            
                                                                                              maglakad o              
                                                                                              umakyat sa              
                                                                                              hagdan?                 

                                                                                                                      Hindi nahihirapan (0)

                                                                                                                      Medyo madalas (1)

                                                                                                                      Sobrang dalas (2)

                                                                                                                      *Walang sagot/hindi alam* (9)

                                                                                                                      

  5\.                       (MPEFF)                              Sa tuwing si                                         
                                                                 (PANGALAN) ay                                        
                                                                 nahihirapan                                          
                                                                 \[kapag hindi                                        
                                                                 niya gamit ang                                       
                                                                 kanyang                                              
                                                                 kagamitan\],                                         
                                                                 gaano ang                                            
                                                                 kanyang                                              
                                                                 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.                                                (MPEFFA)                                 Kapag gamit na          
                                                                                              niya ang                
                                                                                              kanyang                 
                                                                                              kagamitan,              
                                                                                              gaano ang               
                                                                                              kanyang                 
                                                                                              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\.                       (MPACT)                              Mayroon bang                                         
                                                                 mga gawain na                                        
                                                                 hindi na                                             
                                                                 magawa ni                                            
                                                                 (PANGALAN)                                           
                                                                 dahil sa                                             
                                                                 problema sa                                          
                                                                 kanyang binti?                                       

                                                                                Wala (1)                              

                                                                                Mayroon (2)                           

                                                                                *Walang                               
                                                                                sagot/hindi                           
                                                                                alam* (9)                             

                                                                                                                      

                                                                 6a.            (MSACTOPEN)                  Anong    
                                                                                                             gawain   
                                                                                                             iyon?    

                                                                                                                      

                                                                                                                      

  7\.                       (MPWORR)                             Gaano ka                                             
                                                                 nag-aalala o                                         
                                                                 nababahala sa                                        
                                                                 kakayahang                                           
                                                                 makalakad o                                          
                                                                 maka-akyat sa                                        
                                                                 hagdan ni                                            
                                                                 (PANGALAN)?                                          

                                                                                Hindi                                 
                                                                                nag-aalala                            
                                                                                (0)                                   

                                                                                Bahagyang                             
                                                                                nag-aalala                            
                                                                                (1)                                   

                                                                                Sobrang                               
                                                                                nag-aalala                            
                                                                                (2)                                   

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

  ------ ------------------ ------------- -------------- ------------- ----------- ------------------ --- -------------------
  8\.    (MPINSIDE)                       Si (PANGALAN)                                                   
                                          ba ay may                                                       
                                          kahirapang                                                      
                                          kumilos sa                                                      
                                          loob ng inyong                                                  
                                          tahanan?                                                        

                                                         Hindi kayang                                     
                                                         gawin (3)                                        

                                                         Sobrang                                          
                                                         nahihirapan                                      
                                                         (2)                                              

                                                         Bahagyang                                        
                                                         nahihirapan                                      
                                                         (1)                                              

                                                         Hindi                                            
                                                         nahihirapan                                      
                                                         (0)                                              

                                                         *Walang                                          
                                                         sagot/hindi                                      
                                                         alam* (9)                                        

                                                                                                          

  9\.    (MPOUTSIDE)                      Si (PANGALAN)                                                   
                                          ba ay may                                                       
                                          kahirapang                                                      
                                          lumabas sa                                                      
                                          inyong                                                          
                                          tahanan?                                                        

                                                         Hindi kayang                                     
                                                         gawin (3)                                        

                                                         Sobrang                                          
                                                         nahihirapan                                      
                                                         (2)                                              

                                                         Bahagyang                                        
                                                         nahihirapan                                      
                                                         (1)                                              

                                                         Hindi                                            
                                                         nahihirapan                                      
                                                         (0)                                              

                                                         *Walang                                          
                                                         sagot/hindi                                      
                                                         alam* (9)                                        

                                                                                                          

  10\.   (MPLONG)                         Si (PANGALAN)                                                   
                                          ba ay                                                           
                                          nahihirapang                                                    
                                          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 siya lang at                                                                                
         walang                                                                                           
         gamit-pantulong,                                                                                 
         si (PANGALAN) ba                                                                                 
         ay may kahirapang                                                                                
         ...                                                                                              

  a\.                       (MPQUARTER)                                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\.                       (MPSTEPS)                                  Pag-akyat                          
                                                                       ng sampung                         
                                                                       hakbang na                         
                                                                       walang                             
                                                                       pahinga?                           

                                                                                   Oo (1)                 Hindi (2)

                                                                                   *Walang                
                                                                                   sagot/hindi alam*      
                                                                                   (9)                    

  c\.                       (MPSTAND)                                  Tumayo sa                          
                                                                       kanyang mga                        
                                                                       paa ng                             
                                                                       dalawang                           
                                                                       oras?                              

                                                                                   Oo (1)                 Hindi (2)

                                                                                   *Walang                
                                                                                   sagot/hindi alam*      
                                                                                   (9)                    

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

                                                                                   Oo (1)                 Hindi (2)

                                                                                   *Walang                
                                                                                   sagot/hindi alam*      
                                                                                   (9)                    

  e\.                       (MPSTOOP)                                  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: 14%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 47%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">5.</td>
<td>(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="11"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="5">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Oo, kaunnting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="11">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">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="odd">
<td></td>
<td colspan="2">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="even">
<td></td>
<td colspan="2">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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(SSWHY)</td>
<td colspan="7">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>2 – 3 Only if Respondent reported any
difficulty with self-care:</strong></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">2<strong>.</strong></td>
<td colspan="2">(SSDIFF)</td>
<td colspan="7">Gaano ka kadalas nahihirapang mag-alaga ng iyong
sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nahihirapan(0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">3.</td>
<td colspan="2">(SSEFF)</td>
<td colspan="7">Sa tuwing ikaw ay nahihirapan, gaano ang iyong
ginagawang pagsisikap upang maalagaan ang iyong sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Walang pagsisikap (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Kaunting pagsisikap (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang pagsisikap (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="11"><strong><u>ASK EVERYONE</u></strong></td>
</tr>
<tr class="odd">
<td colspan="2">4.</td>
<td colspan="2">(SSWORR)</td>
<td colspan="7">Gaano ka nag-aalala o nababahala sa iyong kakayahang
maalagaan ang iyong sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang nag-aalala (2)</td>
</tr>
<tr class="odd">
<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)                                         
  ----- ------------------ ------------ ----------------- --------------- ------------- --------------------- -- -- ------- ----------------------

SELF-CARE---PROXY-REPORT

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 14%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 47%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">5.</td>
<td>(SPSCARE)</td>
<td colspan="7"><h2
id="si-pangalan-ba-ay-may-kahirapan-sa-pag-aalaga-ng-kanyang-sarili-katulad-ng-pagligo-o-pagbihis">Si
(PANGALAN) ba ay may kahirapan sa pag-aalaga ng kanyang sarili, katulad
ng pagligo o pagbihis? </h2></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="5">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="11">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="2">(SPREPE)</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="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="2">(SPOPT)</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="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="2">(SPCLARI)</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="odd">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="3">1.</td>
<td>(SPWHY)</td>
<td colspan="7">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>2 – 3 Only if Respondent reported any
difficulty with self-care:</strong></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">2<strong>.</strong></td>
<td colspan="2">(SPDIFF)</td>
<td colspan="7">Gaano siya kadalas nahihirapang mag-alaga ng kanyang
sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="2">3.</td>
<td colspan="2">(SPEFF)</td>
<td colspan="7">Sa tuwing si (PANGALAN) ay nahihirapan, gaano ang
kanyang ginagawang pagsisikap upang maalagaan ang kanyang sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Walang pagsisikap (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Kaunting pagsisikap (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang pagsisikap (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="11"><strong><u>ASK EVERYONE</u></strong></td>
</tr>
<tr class="odd">
<td colspan="2">4.</td>
<td colspan="2">(SPWORR)</td>
<td colspan="7">Gaano ka nag-aalala o nababahala sa kakayahang maalagaan
ni (PANGALAN) ang kanyang sarili?</td>
</tr>
<tr class="even">
<td colspan="4" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="5">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5">Sobrang nag-aalala (2)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="5"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

  ----- ------------------ ------------ ----------------- --------------- ------------- ---------------------- -- -- ------- -----------------------
  5\.   Kung siya lang at                                                                                                    
        walang                                                                                                               
        gamit-pantulong,                                                                                                     
        si (PANGALAN) ba                                                                                                     
        ay may kahirapang                                                                                                    
        ...                                                                                                                  

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

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

  b\.                      (SPHAND)                       Iabot ang                                                          
                                                          kanyang kamay                                                      
                                                          para                                                               
                                                          makipagkamay?                                                      

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

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

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

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

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

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

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

  f\.                      (SPHAIR)                       Magsuklay ng                                                       
                                                          buhok?                                                             

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

  g\.                      (SPFEED)                       Pakainin ang                                                       
                                                          sarili?                                                            

                                                                                        Oo (1)                               Hindi (2)

                                                                                        *Walang sagot/hindi                  
                                                                                        alam* (9)                            

                                                                                                                             

  6\.   (SPDAILY)                       Si (PANGALAN) ba                                                                     
                                        ay                                                                                   
                                        nangangailangan                                                                      
                                        ng taong tutulong                                                                    
                                        sa pang-araw-araw                                                                    
                                        niyang gawain                                                                        
                                        kagaya ng                                                                            
                                        pagkain, pagligo,                                                                    
                                        pagbihis o                                                                           
                                        pagpunta sa                                                                          
                                        palikuran?                                                                           

                                                                          Oo (1)                                     Hindi   
                                                                                                                     (2)     

                                                                          *Walang                                            
                                                                          sagot/hindi                                        
                                                                          alam* (9)                                          

  7\.   (SPOBJECTS)                     Si (PANGALAN) ba                                                                     
                                        ay may kahirapang                                                                    
                                        gamitin ang                                                                          
                                        kanyang 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\.   (SPTIRED)                       Si (PANGALAN) 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        No (2)
                                                                           [repeat]{.underline} any part                                       (1)        
                                                                           of the question?                                                               

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

                            3\.              (TSCLARI)                     ask for                                                             Yes        No (2)
                                                                           [clarification]{.underline}                                         (1)        
                                                                           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)                             
  ----- ------------ ------------------ -------------------------- ---- ----------------------

**COMMUNICATION---PROXY-REPORT**

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

                                                                                                                                                       

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

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

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

                                                                                                                                                       

                                                                                                                                                       

  1\.                                        (TPWHY)     Bakit ninyo                                                                                   
                                                         nasabi iyon?                                                                                  

                                                                                                                                                       

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

                                                                                                                                                       

  2**.**                          (TPDIFF)               Gaano siya                                                                                    
                                                         kadalas                                                                                       
                                                         nahihirapang                                                                                  
                                                         umintindi o                                                                                   
                                                         maintindihan?                                                                                 

                                                                                                         Hindi nahihirapan (0)                         

                                                                                                         Medyo madalas (1)                             

                                                                                                         Sobrang dalas (2)                             

                                                                                                         *Walang sagot/hindi alam* (9)                 

                                                                                                                                                       

  3\.                             (TPEFF)                Sa tuwing si                                                                                  
                                                         (PANGALAN) ay                                                                                 
                                                         nahihirapan,                                                                                  
                                                         gaano ang kanyang                                                                             
                                                         ginagawang                                                                                    
                                                         pagsisikap upang                                                                              
                                                         makaintindi o                                                                                 
                                                         maintindihan?                                                                                 

                                                                                                         Walang pagsisikap (0)                         

                                                                                                         Kaunting pagsisikap (1)                       

                                                                                                         Sobrang pagsisikap (2)                        

                                                                                                         *Walang sagot/hindi alam* (9)                 

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

  4\.                             (TPWORR)               Gaano ka                                                                                      
                                                         nag-aalala o                                                                                  
                                                         nababahala sa                                                                                 
                                                         kakayahan ni                                                                                  
                                                         (PANGALAN) upang                                                                              
                                                         umintindi o                                                                                   
                                                         maintindihan?                                                                                 

                                                                                                         Hindi nag-aalala (0)                          

                                                                                                         Bahagyang nag-aalala (1)                      

                                                                                                         Sobrang nag-aalala (2)                        

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

  ----- ------------ ------------------ -------------------------- ---- ----------------------
  5\.   (TPSAY)      Si (PANGALAN) 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\.   (TPCONVO)    SI (PANGALAN) 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\.   (TPFRIEND)   Si (PANGALAN) ba                                   
                     ay may kahirapang                                  
                     makipagkaibigan?                                   

                                        Oo (1)                          Hindi (2)

                                        *Walang sagot/hindi alam*       
                                        (9)                             

                                                                        

  8\.   (TPSHY)      Si (PANGALAN) 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(2)      Katamtamang                Hindi        
                                                                     (4)                                                                                                                            maganda                       ganda (1)                  maganda      
                                                                                                                                                                                                    (3)                                                      (0)          

                                                                                   *Walang                                                                                                                                                                                
                                                                                   sagot/hindi                                                                                                                                                                            
                                                                                   alam* (9)                                                                                                                                                                              

                                                                                                                                                                                                                                                                          

  Did the                                                                                                                                                                                                                                                                 
  respondent....                                                                                                                                                                                                                                                          

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

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

                   3\.                 (GSCLARI)                                                                                      ask for                                                                                                       Yes                   No
                                                                                                                                      [clarification]{.underline}                                                                                   (1)                   (2)
                                                                                                                                      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)                                                                                          
  ---------------- ----- ------------- ------------ -- ------------- ------------- ------------- --------------------- -------------- ----------------------------- -- -------------------- ------- --------- --- ------------ -- ------------- --- ----- -- --------- -- -----

**GENERAL HEALTH---PROXY-REPORT**

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

                                                                                                                                                                                                                                                                                        

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

                                                                                   *Walang                                                                                                                                                                                              
                                                                                   sagot/hindi                                                                                                                                                                                          
                                                                                   alam* (9)                                                                                                                                                                                            

                                                                                                                                                                                                                                                                                        

  Did the                                                                                                                                                                                                                                                                               
  respondent....                                                                                                                                                                                                                                                                        

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

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

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

                                                                                                                                                                                                                                                                                        

  1\.                                  (GPWHY)                                                                         Bakit ninyo                                                                                                                                                      
                                                                                                                       nasabi iyon?                                                                                                                                                     

                                                                                                                                                                                                                                                                                        

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

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

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

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

  3\.                    (GPCOND)                                                                                      Si (PANGALAN)                                                                                                                                                    
                                                                                                                       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?