[p.35]
The items below show the exact content and wording of the basic questionnaire used in the nationwide household survey of the US National Health Survey. The actual questionnaire is designed for a household as a unit and includes additional spaces for reports on more than one person, condition, accident, or hospitalization. Such repetitive spaces are omitted in this illustration.
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE
NATIONAL HEALTH SURVEY
1. Questionnaire ________of ________ questionnaires
2. (a) Address or description of location ________
(b) Mailing address if not shown in (a): Include city, zone and state ________
[] Other unit
d. Name of special dwelling place ________
Code ________
3. Iden. Code ________
3(a) Reg. Office code ________
7a. Segment type ________
L
Ask them 9 and 10 ONLY if "rural" box is checked.
[] All other
9. Do you own or rent this place?
[] Rent (Ask 10 (b))
[] Rent Free (ask 10 (a))
10. If "own" or "rent free" in Item 9, ask:
a. Does this place have 10 or more acres?
[] No (d)
If "rent" in item 9, ask:
b. Does the place you rent have 10 or more acres?
[] No (d)
c. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $50 or more?
[] No
d. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $250 or more?
[] No
E
If this questionnaire is for "extra" unit in NTA or B segment enter:
Serial No. ________, "Extra" unit discovered by item No. ________
11. Ask in all segments:
Besides the people mentioned, does anyone else get to his quarters by using the entrance to (specify item 2a address and point to entrance where convenient)?
[] No
12. Ask in all segments: (ask only of item 2a address indicates a single-unit structure).
Are there any occupied or vacant living quarters besides your own- in the basement? on this floor? or on any other floor of this building?
[] No
13. Ask in TA and NTA segments only. (Ask at all units EXCEPT in apartment houses)
Is there any other building on this property for people to live in-either occupied or vacant?
[] No
14. What is the telephone number here?
[] No phone
15. Record of calls at households
Item 1
Time ____
Com ____
[option for upto 4 entries].
Date ____
Time ____
Com. ____
Time ____
Com ____
[Comment: upto 4 entries]
Date ____
Time ____
Com. ____
Time ____
Com ____
[Comment: upto 4 entries]
Date ____
Time ____
Com. ____
Time ____
Com ____
[Comment: upto 4 entries]
Date ____
Time ____
Com. ____
Time ____
Com ____
[Comment: upto 4 entries]
Date ____
Time ____
Com. ____
16. Reason for non-interview
Type A
Reason:
[] No one at home-repeated calls
[] Temporarily absent
[] Other (Specify)
Reason:
[] Vacant-seasonal
[] Usual residence elsewhere
[] Armed Forces
[] Other (specify)
Reason:
[] In sample by mistake
[] Eliminated in sub-sample
[] Other (Specify)
Interview not obtained for:
Because: ________
17. Signature of interviewer ________
Table X- living quarters determinations at listed address
[option for upto 5 entry sets]
3. Are these (Specify location) quarters for more than one group of people?
b.[] No
Use or characteristics:
5. Occupied: do the occupants of these (specify location) quarters live and eat with any other group of people?
b.[] No
All Quarters: Do these (specify location) quarters have:
6. Direct access from the outside or through a common hall?
b.[] No
7. A kitchen or cooking equipment for exclusive use?
b.[] No
Classification:
8. Not a separate unit (add occupants to this questionnaire)________
9. Fill separate questionnaire and interview
b.[] Other unit
If HY in B segment ask:
10. In what year were these (specify location) quarters created? (if 1959 or 1960 also specify "F" if first hall or "L" if last hall) ________
11. (if before July 1960) What was the name of the household head of these quarters on April 1, 1960? ________