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Choose... Laki-laki Perempuan

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Choose... Staf WVI Mitra Operating Model Board Pemerintah Lembaga Usaha Relawan Masyarakat Umum Lainnya

Apakah Anda mengalami kesulitan atau gangguan penglihatan meskipun memakai kacamata?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan pendengaran?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan berjalan atau naik tangga?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan menggunakan/ menggerakkan tangan/jari?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan dalam hal mengingat atau berkonsentrasi?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami gangguan perilaku dan atau emosional?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan berbicara dan/atau memahami atau berkomunikasi dengan orang lain?

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

Apakah Anda mengalami kesulitan atau gangguan untuk mengurus diri sendiri? (seperti mandi, makan, berpakaian, buang air besar, buang air kecil)

Tidak, tidak kesulitan Ya, sedikit kesulitan Ya, banyak kesulitan Tidak bisa sama sekali

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