| FIGURE 32 |
Harris and Associates
Survival Literacy Study - 1970 |
| A. |
Person applying for medical
assistance:
_________________________________________________________ |
| B. |
Do you earn a salary or wage? _______ Are you
self-employed? _______
If employed, write below:
Employer's name and
address: __________________________________
Total wages or income:
__________ per (week, month, etc.) ________
How many hours per week are you
usually employed? _____________ |
| C. |
Is any payment for room and board or other
contributions received from any other person who resides in the household?
_____
If another person paying, answer the following:
Name of person
making payment or contribution: ________________
Amount paid: _____________
(per week, month, etc.)____________ |
| D. |
Do you have cash savings or other liquid
assets such as savings accounts, savings bonds, stocks, bonds, etc., or any
claim pending for personal injury, disease, or disability? _______
If you
have cash or other savings, answer the following:
Types of assets:
____________________________________
Name of bank, company invested in:
_____________________
Type of policy:
_____________________________________
(INDICATE WHETHER WHOLE LIFE, 20
PAYMENT LIFE, 20-YEAR ENDOWMENT, TERM INSURANCE, FAMILY PLAN, ETC.) |
| F. |
Do you expect to incur any medical expenses
within the next three months? _____
If yes, what type of medical services is
required? __________________
Estimated cost: _______________ |
| G. |
Do you have any physical or mental handicap or
disability? ______
If you have handicap or disability, write
below:
Description of handicap or disability:
_______________________
Date started: ____________ |
| PLEASE MAKE SURE
ALL QUESTIONS HAVE BEEN ANSWERED. IF YOU ARE NOT SURE OF AN ANSWER TO ANY ITEM,
DRAW A LINE THROUGH THE SPACE PROVIDED FOR THE ANSWER. |
|
| (N.B. Drawing a line through the space was considered a correct
answer.) |
Source: D.L.Fisher (1978, January). Functional literacy and the
schools. Washington, DC:
U.S. Department of Health,
Education and Welfare, National Institute of Education, p42. |
|
Years of Education |
Percent Correct
Score
Range |
8th grade
or
less |
High
School |
College |
| 90 - 100 |
54a |
66 |
74 |
| 80 - 89 |
17 |
17 |
16 |
| 70 - 79 |
9 |
9 |
6 |
| a - Percentage of respondents falling in the
given percent correct score range |
Source: Congressional Record, November 18,
1970, Page E9722, Chart XVIII.
|