**APPENDIX 4**

**PROXY-REPORT COGNITIVE QUESTIONNAIRE IN FILIPINO**

**National Statistics Office**

**Philippines**

**WASHINGTON GROUP ON DISABILITY STATISTICS**

**Cognitive Testing**

**SECTION 1. Face Sheet**

***Instructions to the respondent:***

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

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

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

+---+------------------------------+---+--------------------------------+
| # | GEOGRAPHIC IDENTIFICATION    |   |                                |
| # |                              |   |                                |
| # |                              |   |                                |
| # |                              |   |                                |
|   |                              |   |                                |
| F |                              |   |                                |
| 1 |                              |   |                                |
+---+------------------------------+---+--------------------------------+
| # | RESPONDENT'S NAME:           |   |                                |
| # |                              |   |                                |
| # |                              |   |                                |
| # |                              |   |                                |
|   |                              |   |                                |
| F |                              |   |                                |
| 2 |                              |   |                                |
+---+------------------------------+---+--------------------------------+
|   | (Family Name, First Name)    |   |                                |
+---+------------------------------+---+--------------------------------+
| # | a\) INTERVIEW DATE           |   | \_\_\_ \_\_\_/\_\_\_           |
| # |                              |   | \_\_\_/\_\_\_ \_\_\_           |
| # | b\) STARTING TIME            |   |                                |
| # |                              |   | day month year                 |
|   | c\) TIME INTERVIEW ENDED     |   |                                |
| F |                              |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
| 3 | d\) TOTAL DURATION           |   | >                              |
|   |                              |   | > hrs min                      |
|   |                              |   | >                              |
|   |                              |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
|   |                              |   | >                              |
|   |                              |   | > hrs min                      |
|   |                              |   | >                              |
|   |                              |   | > \_\_\_ \_\_\_/\_\_\_ \_\_\_  |
|   |                              |   | >                              |
|   |                              |   | > hrs min                      |
+---+------------------------------+---+--------------------------------+
| # | LANGUAGE                     |   | Filipino 1                     |
| # |                              |   |                                |
|   |                              |   | English 2                      |
| F |                              |   |                                |
| 4 |                              |   | Others 3                       |
|   |                              |   |                                |
|   |                              |   | (pls specify)                  |
|   |                              |   | \_                             |
|   |                              |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+---+------------------------------+---+--------------------------------+
| # | ## COUNTRY                   |   | **[Philippines]{.underline}**  |
| # |                              |   |                                |
|   |                              |   |                                |
| F |                              |   |                                |
| 5 |                              |   |                                |
+---+------------------------------+---+--------------------------------+
| * |                              | * |                                |
| * |                              | * |                                |
| I |                              | S |                                |
| N |                              | U |                                |
| T |                              | P |                                |
| E |                              | E |                                |
| R |                              | R |                                |
| V |                              | V |                                |
| I |                              | I |                                |
| E |                              | O |                                |
| W |                              | R |                                |
| E |                              | ' |                                |
| R |                              | S |                                |
| ' |                              | N |                                |
| S |                              | A |                                |
| N |                              | M |                                |
| A |                              | E |                                |
| M |                              | : |                                |
| E |                              | * |                                |
| : |                              | * |                                |
| * |                              |   |                                |
| * |                              |   |                                |
+---+------------------------------+---+--------------------------------+

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 15%" />
<col style="width: 13%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 21%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><h6
id="section-2.-demographic-and-background-information"> SECTION 2.
Demographic and Background Information</h6></td>
</tr>
<tr class="even">
<td><p id="section" class="heading"></p></td>
<td colspan="9"><em>RECORD SEX AS OBSERVED</em></td>
<td colspan="4"><p>Female 1</p>
<p>Male 2</p></td>
</tr>
<tr class="odd">
<td><strong>1</strong></td>
<td colspan="9">Ilang taon na kayo sa kasalukuyan?</td>
<td colspan="4">___/___years</td>
</tr>
<tr class="even">
<td><strong>2</strong></td>
<td colspan="9"><p>Sa kabuuan, ilang taon ang inyong ginugol sa
pag-aaral</p>
<p>sa eskuwelahan, kolehiyo o unibersidad?</p></td>
<td colspan="4">___/___ 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-1"></h4>
<h4 id="section-2">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="4"><p>5 Never married</p>
<p>6 Living with partner</p></td>
<td colspan="2"><p>7 Don’t know/</p>
<p>Refused</p></td>
</tr>
<tr class="odd">
<td><h4 id="section-3"></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-4"></h4></td>
<td colspan="2"><p>J</p>
<p>R</p>
<p>C</p>
<p>M</p></td>
<td colspan="2"></td>
<td colspan="2"><p>F</p>
<p>S</p>
<p>K</p>
<p>P</p></td>
<td colspan="2"></td>
<td colspan="2"><p>D</p>
<p>H</p>
<p>U</p>
<p>N</p></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td><h4 id="section-5"></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 --PROXY-REPORT**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 14%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 23%" />
<col style="width: 5%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<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>1.</td>
<td colspan="5">(VPVISION)</td>
<td colspan="10"><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="4" rowspan="5"></td>
<td colspan="4"></td>
<td colspan="8">Hindi, walang hirap (0)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="8">Oo, kaunting hirap (1)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="8">Oo, sobrang hirap (2)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="8">Hindi kayang gawin (3)</td>
</tr>
<tr class="even">
<td colspan="4"></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="4"></td>
<td colspan="4"></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="5">(VPREPE)</td>
<td colspan="3">need you to <u>repeat</u> any part of the question?</td>
<td></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="5">(VPOPT)</td>
<td colspan="3">have any difficulty using the <u>response
options</u>?</td>
<td></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="5">(VPCLARI)</td>
<td colspan="3">ask for <u>clarification</u> or qualify their
answer?</td>
<td></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="5"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="5">(VPWHY)</td>
<td colspan="10">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td>2.</td>
<td colspan="5">(VPGLASS)</td>
<td colspan="10">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="4" rowspan="2"></td>
<td colspan="4"></td>
<td>Sa lahat ng oras (2)</td>
<td></td>
<td colspan="3">Sa tuwing may ginagawa lamang (1)</td>
<td></td>
<td colspan="2">Hindi gumagamit (0)</td>
</tr>
<tr class="odd">
<td colspan="4"></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>3.</td>
<td colspan="6">(VPDIFF)</td>
<td colspan="9">[Kapag wala siyang suot na salamin], gaano siya kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"></td>
<td colspan="4"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="4"></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="2">3a.</td>
<td colspan="3">(VPDIFFG)</td>
<td colspan="11">Kapag nakasuot na siya ng salamin, gaano siya kadalas
nahihirapang makakita nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"></td>
<td colspan="4"></td>
<td colspan="8">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="8">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="8">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="4"></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---PROXY-REPORT

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 17%" />
<col style="width: 6%" />
<col style="width: 20%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td>2.</td>
<td colspan="6">(HPHEAR)</td>
<td colspan="15"><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="22"></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="22">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">1.</td>
<td colspan="10">(HPREPE)</td>
<td colspan="3">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">2.</td>
<td colspan="10">(HPOPT)</td>
<td colspan="3">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">3.</td>
<td colspan="10">(HPCLARI)</td>
<td colspan="3">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="10"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="22"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="4">(HPWHY)</td>
<td colspan="17">Bakit ninyo nasabi yon?</td>
</tr>
<tr class="even">
<td colspan="22"></td>
</tr>
<tr class="odd">
<td>2.</td>
<td colspan="4">(HPAID)</td>
<td colspan="17">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="5"></td>
<td colspan="4">Sa lahat ng oras (2)</td>
<td></td>
<td colspan="3">Sa tuwing may ginagawa lamang (1)</td>
<td></td>
<td colspan="3">Hindi gumagamit (0)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="12"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="22"></td>
</tr>
<tr class="odd">
<td colspan="22"><strong>3 – 4 Only if respondent reported any
difficulty hearing:</strong></td>
</tr>
<tr class="even">
<td>3.</td>
<td colspan="7">(HPDIFF)</td>
<td colspan="14">[Kapag wala siyang “hearing aid”], gaano siya kadalas
nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"></td>
<td colspan="5"></td>
<td colspan="13">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="13">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="13">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="13"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="22"><strong>Hearing aid users only:</strong></td>
</tr>
<tr class="even">
<td colspan="2">3a.</td>
<td colspan="7">(HPDIFFA)</td>
<td colspan="13">Kapag gumagamit na siya ng “hearing aid”, gaano siya
kadalas nahihirapang makarinig nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="9" 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>

  ----------------------- ---------- ----- ------------- ------------- ------------ --------------- ----------- --- ---------------------------------
  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
                                                                                                                                                               beses sa                   (0)
                                                                                                                                                               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---PROXY-REPORT

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 21%" />
<col style="width: 4%" />
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td>3.</td>
<td colspan="3">(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="3" rowspan="5"></td>
<td colspan="2"></td>
<td colspan="10">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="10">Oo, konting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="10">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="15">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td>1.</td>
<td colspan="5">(CPREPE)</td>
<td colspan="3">Need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td>2.</td>
<td colspan="5">(CPOPT)</td>
<td colspan="3">Have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td>3.</td>
<td colspan="5">(CPCLARI)</td>
<td colspan="3">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="3">(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>2.</td>
<td colspan="5">(CPREMCON)</td>
<td colspan="9">Si (PANGALAN) ba ay may kahirapang makaalala o
makapag-concentrate (makapagtuon ng pansin) o pareho?</td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"></td>
<td colspan="3"></td>
<td colspan="2">Makaalala (remembering) (1)</td>
<td></td>
<td colspan="3">Makapag-concentrate (makapagtuon ng pansin)(2)</td>
<td colspan="2"></td>
<td>Pareho (both) (3)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td>3<strong>.</strong></td>
<td colspan="5">(CPDIFF)</td>
<td colspan="9">Gaano siya kadalas nahihirapang makaalala o
mag-concentrate (magtuon ng pansin) nang maayos?</td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="9">Hindi nahihirapan(0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td>4.</td>
<td colspan="5">(CPEFF)</td>
<td colspan="9">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="3" rowspan="4"></td>
<td colspan="3"></td>
<td colspan="9">Walang pagsisiskap (0)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9">Kaunting pagsisikap (1)</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="9">Sobrang pagsisikap (2)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 26%" />
</colgroup>
<tbody>
<tr class="odd">
<td>5.</td>
<td colspan="4">(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 colspan="2"></td>
<td colspan="9">dahil sa marami siyang ginagawa? (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">dahil sa kanyang pagtanda? (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">o dahil sa iba pang kadahilanan? (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="15"><u>ASK EVERYONE</u></td>
</tr>
<tr class="even">
<td colspan="2">6.</td>
<td colspan="5">(CPACT)</td>
<td colspan="8">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 colspan="2"></td>
<td colspan="9">Wala (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Mayroon (2) (Go to 6a. CSACTOPEN)</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="6"></td>
<td colspan="3">6a.</td>
<td colspan="2">(CPACTOPEN)</td>
<td colspan="4">Anong gawain iyon?</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="2">7.</td>
<td colspan="5">(CPWORR)</td>
<td colspan="8">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 colspan="2"></td>
<td colspan="9">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9">Sobrang nag-aalala (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">8.</td>
<td colspan="13">Si (PANGALAN) ay may kahirapan. . .</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="3">a.</td>
<td colspan="5">(CPNAMES)</td>
<td colspan="7">Sa pag-alala ng mga pangalan ng tao o lugar?</td>
</tr>
<tr class="even">
<td colspan="8"></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="15"></td>
</tr>
<tr class="even">
<td colspan="3">b.</td>
<td colspan="5">(CPAPPT)</td>
<td colspan="7">Sa pag-alala ng pinagkasunduang pagkikita
(appointments)?</td>
</tr>
<tr class="odd">
<td colspan="8"></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="15"></td>
</tr>
<tr class="odd">
<td colspan="3">c.</td>
<td colspan="5">(CPPLACES)</td>
<td colspan="7">Sa pag-alala kung paano makarating sa pamilyar na
lugar?</td>
</tr>
<tr class="even">
<td colspan="8"></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="15"></td>
</tr>
<tr class="even">
<td colspan="3">d.</td>
<td colspan="5">(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="8"></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 | (      | S |                                                        |
| \ | CPTEN) | i |                                                        |
| . |        | ( |                                                        |
|   |        | P |                                                        |
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|   |        | G |                                                        |
|   |        | A |                                                        |
|   |        | L |                                                        |
|   |        | A |                                                        |
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|   |        | ) |                                                        |
|   |        | b |                                                        |
|   |        | a |                                                        |
|   |        | a |                                                        |
|   |        | y |                                                        |
|   |        | m |                                                        |
|   |        | a |                                                        |
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|   |        | k |                                                        |
|   |        | a |                                                        |
|   |        | h |                                                        |
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|   |        | a |                                                        |
|   |        | p |                                                        |
|   |        | a |                                                        |
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|   |        | g |                                                        |
|   |        | m |                                                        |
|   |        | a |                                                        |
|   |        | k |                                                        |
|   |        | a |                                                        |
|   |        | p |                                                        |
|   |        | a |                                                        |
|   |        | g |                                                        |
|   |        | - |                                                        |
|   |        | c |                                                        |
|   |        | o |                                                        |
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|   |        | c |                                                        |
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|   |        | t |                                                        |
|   |        | r |                                                        |
|   |        | a |                                                        |
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|   |        |   |                                                        |
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|   |        | o |                                                        |
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|   |        | a |                                                        |
|   |        | m |                                                        |
|   |        | p |                                                        |
|   |        | u |                                                        |
|   |        | n |                                                        |
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|   |        | m |                                                        |
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|   |        | o |                                                        |
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+---+--------+---+--------------------------------------------------------+
|   |        | H |                                                        |
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|   |        | n |                                                        |
|   |        | d |                                                        |
|   |        | i |                                                        |
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|   |        | a |                                                        |
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|   |        | n |                                                        |
|   |        | ( |                                                        |
|   |        | 0 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
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|   |        | h |                                                        |
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|   |        | p |                                                        |
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|   |        | ( |                                                        |
|   |        | 1 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | S |                                                        |
|   |        | o |                                                        |
|   |        | b |                                                        |
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+---+--------+---+--------------------------------------------------------+
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|   |        | 3 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | * |                                                        |
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|   |        | a |                                                        |
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|   |        | * |                                                        |
|   |        | ( |                                                        |
|   |        | 9 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        |   |                                                        |
+---+--------+---+--------------------------------------------------------+
| 1 | (      | S |                                                        |
| 0 | CPNEW) | i |                                                        |
| \ |        | ( |                                                        |
| . |        | P |                                                        |
|   |        | A |                                                        |
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|   |        | a |                                                        |
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|   |        | ? |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | H |                                                        |
|   |        | i |                                                        |
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|   |        | d |                                                        |
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|   |        | n |                                                        |
|   |        | ( |                                                        |
|   |        | 0 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | B |                                                        |
|   |        | a |                                                        |
|   |        | h |                                                        |
|   |        | a |                                                        |
|   |        | g |                                                        |
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|   |        | a |                                                        |
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|   |        | g |                                                        |
|   |        | n |                                                        |
|   |        | a |                                                        |
|   |        | h |                                                        |
|   |        | i |                                                        |
|   |        | h |                                                        |
|   |        | i |                                                        |
|   |        | r |                                                        |
|   |        | a |                                                        |
|   |        | p |                                                        |
|   |        | a |                                                        |
|   |        | n |                                                        |
|   |        | ( |                                                        |
|   |        | 1 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | S |                                                        |
|   |        | o |                                                        |
|   |        | b |                                                        |
|   |        | r |                                                        |
|   |        | a |                                                        |
|   |        | n |                                                        |
|   |        | g |                                                        |
|   |        | n |                                                        |
|   |        | a |                                                        |
|   |        | h |                                                        |
|   |        | i |                                                        |
|   |        | h |                                                        |
|   |        | i |                                                        |
|   |        | r |                                                        |
|   |        | a |                                                        |
|   |        | p |                                                        |
|   |        | a |                                                        |
|   |        | n |                                                        |
|   |        | ( |                                                        |
|   |        | 2 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | H |                                                        |
|   |        | i |                                                        |
|   |        | n |                                                        |
|   |        | d |                                                        |
|   |        | i |                                                        |
|   |        | k |                                                        |
|   |        | a |                                                        |
|   |        | y |                                                        |
|   |        | a |                                                        |
|   |        | n |                                                        |
|   |        | g |                                                        |
|   |        | g |                                                        |
|   |        | a |                                                        |
|   |        | w |                                                        |
|   |        | i |                                                        |
|   |        | n |                                                        |
|   |        | ( |                                                        |
|   |        | 3 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        | * |                                                        |
|   |        | W |                                                        |
|   |        | a |                                                        |
|   |        | l |                                                        |
|   |        | a |                                                        |
|   |        | n |                                                        |
|   |        | g |                                                        |
|   |        | s |                                                        |
|   |        | a |                                                        |
|   |        | g |                                                        |
|   |        | o |                                                        |
|   |        | t |                                                        |
|   |        | / |                                                        |
|   |        | h |                                                        |
|   |        | i |                                                        |
|   |        | n |                                                        |
|   |        | d |                                                        |
|   |        | i |                                                        |
|   |        | a |                                                        |
|   |        | l |                                                        |
|   |        | a |                                                        |
|   |        | m |                                                        |
|   |        | * |                                                        |
|   |        | ( |                                                        |
|   |        | 9 |                                                        |
|   |        | ) |                                                        |
+---+--------+---+--------------------------------------------------------+
|   |        |   |                                                        |
+---+--------+---+--------------------------------------------------------+
| 1 | (CP    |   | Si (PANGALAN) ba ay may kahirapang makahanap ng        |
| 1 | SOLUT) |   | 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)                      |
+---+--------+---+--------------------------------------------------------+

###  {#section-6}

###  {#section-7}

###  {#section-8}

###  {#section-9}

###  {#section-10}

###  {#section-11}

###  {#section-12}

###  {#section-13}

###  {#section-14}

###  {#section-15}

### LOWER MOBILITY---PROXY-REPORT

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 16%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td>4.</td>
<td colspan="3">(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="3" rowspan="5"></td>
<td></td>
<td colspan="13">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="13">Oo, konting hirap (1)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="13">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="13">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="13"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td></td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="17">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td>1.</td>
<td colspan="5">(MPREPE)</td>
<td colspan="4">need you to <u>repeat</u> any part of the question?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td>2.</td>
<td colspan="5">(MPOPT)</td>
<td colspan="4">have any difficulty using the <u>response
options</u>?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td>3.</td>
<td colspan="5">(MPCLARI)</td>
<td colspan="4">ask for <u>clarification</u> or qualify their
answer?</td>
<td></td>
<td colspan="2">Yes (1)</td>
<td colspan="2"></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5"></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="3">(MPWHY)</td>
<td colspan="13">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td>2.</td>
<td colspan="3">(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="3" rowspan="3"></td>
<td colspan="2"></td>
<td colspan="12">Wala (0)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12">Mayroon (1) (<em>Go to 2a. MSAIDTYPE</em>)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="3">2a.</td>
<td colspan="5">(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>3.</td>
<td colspan="5">(MPWALKSTEP)</td>
<td colspan="11">Si (PANGALAN) ba ay may kahirapan sa paglalakad o
pag-akyat sa hagdan o pareho?</td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"></td>
<td colspan="2"></td>
<td colspan="4">Paglalakad (1)</td>
<td></td>
<td colspan="3">Pag-akyat (2)</td>
<td colspan="2"></td>
<td colspan="2">Pareho (3)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
</tr>
<tr class="even">
<td>4.</td>
<td colspan="5">(MPDIFF)</td>
<td colspan="11">[Kapag wala siyang kagamitan, ….] Gaano siya kadalas
nahihirapang maglakad o umakyat sa hagdan?</td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="4"></td>
<td colspan="2"></td>
<td colspan="12">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12">Medyo madalas (1)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="12">Sobrang dalas (2)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="12"><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---PROXY-REPORT

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 37%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td>5.</td>
<td colspan="5">(SPSCARE)</td>
<td colspan="14"><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="20"></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="5"></td>
<td colspan="5"></td>
<td colspan="10">Hindi, walang hirap (0)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Oo, kaunting hirap (1)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10">Oo, sobrang hirap (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="20">Did the respondent….</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">1.</td>
<td colspan="5">(SPREPE)</td>
<td colspan="4">need you to <u>repeat</u> any part of the question?</td>
<td colspan="2"></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">2.</td>
<td colspan="5">(SPOPT)</td>
<td colspan="4">have any difficulty using the <u>response
options</u>?</td>
<td colspan="2"></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">3.</td>
<td colspan="5">(SPCLARI)</td>
<td colspan="4">ask for <u>clarification</u> or qualify their
answer?</td>
<td colspan="2"></td>
<td colspan="3">Yes (1)</td>
<td></td>
<td>No (2)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="5">(SPWHY)</td>
<td colspan="14">Bakit ninyo nasabi iyon?</td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="20"><strong>2 – 3 Only if Respondent reported any
difficulty with self-care:</strong></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td>2<strong>.</strong></td>
<td colspan="7">(SPDIFF)</td>
<td colspan="12">Gaano siya kadalas nahihirapang mag-alaga ng kanyang
sarili?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="5"></td>
<td colspan="10">Hindi nahihirapan (0)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10">Medyo madalas (1)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Sobrang dalas (2)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td>3.</td>
<td colspan="7">(SPEFF)</td>
<td colspan="12">Sa tuwing si (PANGALAN) ay nahihirapan, gaano ang
kanyang ginagawang pagsisikap upang maalagaan ang kanyang sarili?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="5"></td>
<td colspan="10">Walang pagsisikap (0)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10">Kaunting pagsisikap (1)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Sobrang pagsisikap (2)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="20"><strong><u>ASK EVERYONE</u></strong></td>
</tr>
<tr class="odd">
<td>4.</td>
<td colspan="7">(SPWORR)</td>
<td colspan="12">Gaano ka nag-aalala o nababahala sa kakayahang
maalagaan ni (PANGALAN) ang kanyang sarili?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="4"></td>
<td colspan="5"></td>
<td colspan="10">Hindi nag-aalala (0)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10">Bahagyang nag-aalala (1)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Sobrang nag-aalala (2)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="3">5.</td>
<td colspan="17">Kung siya lang at walang gamit-pantulong, si (PANGALAN)
ba ay may kahirapang …</td>
</tr>
<tr class="odd">
<td colspan="2">a.</td>
<td colspan="5">(SPHEAD)</td>
<td colspan="13">Umabot ng lampas-ulo?</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="2">b.</td>
<td colspan="5">(SPHAND)</td>
<td colspan="13">Iabot ang kanyang kamay para makipagkamay?</td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="2">c.</td>
<td colspan="5">(SPFINGER)</td>
<td colspan="13">Gamitin ang kanyang mga daliri upang mai-butones ang
kamiseta o damit?</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="2">d.</td>
<td colspan="5">(SPSOCK)</td>
<td colspan="13">Magsuot ng medyas o ‘stockings’?</td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="2">e.</td>
<td colspan="5">(SPSHOE)</td>
<td colspan="13">Magtali ng sintas ng sapatos?</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="2">f.</td>
<td colspan="5">(SPHAIR)</td>
<td colspan="13">Magsuklay ng buhok?</td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="odd">
<td colspan="2">g.</td>
<td colspan="5">(SPFEED)</td>
<td colspan="13">Pakainin ang sarili?</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Oo (1)</td>
<td colspan="3"></td>
<td colspan="3">Hindi (2)</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="9"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="3">6.</td>
<td colspan="5">(SPDAILY)</td>
<td colspan="12">Si (PANGALAN) ba ay nangangailangan ng taong tutulong
sa pang-araw-araw niyang gawain kagaya ng pagkain, pagligo, pagbihis o
pagpunta sa palikuran?</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"></td>
<td colspan="5"></td>
<td colspan="2">Oo (1)</td>
<td colspan="4"></td>
<td colspan="4">Hindi (2)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="3">7.</td>
<td colspan="5">(SPOBJECTS)</td>
<td colspan="12">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?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="5"></td>
<td colspan="5"></td>
<td colspan="10">Hindi nahihirapan (0)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Bahagyang nahihirapan (1)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10">Sobrang nahihirapan (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10">Hindi kayang gawin (3)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
<tr class="even">
<td colspan="3">8.</td>
<td colspan="5">(SPTIRED)</td>
<td colspan="12">Si (PANGALAN) ba ay nakakaramdam ng matinding pagod o
lungkot na magbihis o maligo?</td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"></td>
<td colspan="5"></td>
<td colspan="2">Oo (1)</td>
<td colspan="4"></td>
<td colspan="4">Hindi (2)</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="10"><em>Walang sagot/hindi alam</em> (9)</td>
</tr>
</tbody>
</table>

**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 (1)      No (2)
                                                                                                                                                         [repeat]{.underline} any part                    
                                                                                                                                                         of the question?                                 

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

                            3\.                     (TPCLARI)                                                                                            ask for                             Yes (1)      No (2)
                                                                                                                                                         [clarification]{.underline}                      
                                                                                                                                                         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---PROXY-REPOR**

**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                       
  --------------- ------------- -- -------------- --------------- ----------------- ------------ -------- ------------------------------------------------------------

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

^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?