Laserfiche WebLink
b. Where did this person live 5 years ago? <br />Name of city, town, or post office <br />Did this person live inside the limits of the <br />city or town? <br />^ Yes <br />^ No, outside the city/town limits <br />Name of county <br />Name of state <br />ZIP Code <br />Does this person have any of the following <br />long-lasting conditions: <br />Yes No <br />a. Blindness, deafness, or a severe <br />vision or hearing impairment? ^ ^ <br />b. A condition that substantially limits <br />one or more basic physical activities ° ';.` <br />such as walking, climbing stairs, "~ ' <br />reaching, lifting, or carrying? ^'~ __,C,' <br />`~.~~. ~~ <br />,~,~ . <br />Because of a physical, mental, or emot:oaaf` -' <br />condition lasting 6 months or more;;;daes~ <br />this person have any difficulty in d~:iny::3ny of <br />the following activities: '~'~~ ` : . <br />~` '~ ,!~ <br />_-- Yes No <br />, <br />a. Learning, remembering, or`"~~;= -' <br />.5,; <br />concentrating? <br />- <br />~ <br /> <br />^ <br /> <br />^ <br />~ <br />_., <br />~ <br />b. Dressing, bathing, or`~ettieig around <br />inside the home? ^ ^ <br />c. (Answer if this person is 16 YEARS OLD <br />OR OVER.) Going outside the home <br />alone to shop or visit a doctor's office? ^ ^ <br />d. (Answer if this person is 16 YEARS OLD <br />OR OVER.) Working at a job or business? ^ ^ <br />Was this person under 15 years of age on <br />April 1, 20007 <br />^ Yes -~ Skip to 33 <br />^ No <br />~, iiiiiiiiiuiii <br />a. Does this person have any of his/her own <br />grandchildren under the age of 18 living in this <br />house or apartment? <br />^ Yes <br />^ No --~ Skip ro 20a <br />b. Is this grandparent currently responsible for <br />most of the basic needs of any grandchild(ren) <br />under the age of 18 who live(s) in this house <br />or apartment? <br />^ Yes <br />^ No ~ Skip to 20a <br />c How long has this grandparent been responsible <br />for the(se) grandchild(ren)? If the grandparent is <br />financially responsible ~orrri%re than one grandchild, .answer <br />the question for the~~rrndchild for whom the grandparent <br />has been responsill~ ror. the longest period of time. <br />^ Less thae~e ~monlis <br />^ 6 to 11 .~nonLhs <br />^ 1 0(`2 years , <br />.~ <br /><<1 or~~~-;ears <br />5.years or more <br />a. F;as this person ever served on active du in <br />~~trie U.S. Armed Forces, military Reserves, ory <br />;. National Guard? Active duty does not include training <br />for the Reserves or National Guard, but DOES include <br />activation, for example, for the Persian Gulf War. <br />^ Yes, now on active duty <br />^ Yes, on alive duty in past, but not now <br />^ No, training for Reserves or National <br />Guard only --~ Skip io 21 <br />^ No, never served in the military -~ Skip to 21 <br />b. When did this person serve on active duty <br />in the U.S. Armed Forces? Mark Q a box for <br />EACH period in which this person served. <br />^ April 1995 or later <br />^ August 1990 to March 1995 (including Persian Gulf War) <br />^ September 1980 to July 1990 <br />^ May 1975 to August 1980 <br />^ Vietnam era (August 1964-April 1975) <br />^ February 1955 to July 1964 <br />^ Korean conflict (June 1950-January 1955) <br />^ World War II (September 1940-July 1947) <br />^ Some other time <br />G In total, how many years of active-duty military <br />service has this person had? <br />^ Less than 2 years <br />^ 2 years or more <br />Form 0.616 <br />