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[p.36]


PERSON

1. a. What is the name of the head of household? (enter name in first column)

Last name ________
First name and initial ________

b. What are the names of all other persons who live here?

(List all persons who live here) ________

c. I have listed (read names). Is there anyone else staying here now such as friends, relatives or roomers?

[] Yes (list)
[] No

d. Have I missed anyone who usually lives here but is now-

Temporarily in a hospital?
[] Yes (list)
[] No
Away on business?
[] Yes (list)
[] No
On a visit or vacation?
[] Yes (list)
[] No

e. Do any of the people in this household have a home elsewhere?

[] Yes (apply household membership rules; if not a houshold member, delete)
[] No (leave on questionnaire)

If any adult males listed, ask:
f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the united states?

[] Yes (delete)
[] No

2. How are you related to the head of the household? (Enter relationship to head, for example: head , wife, daughter, grandson, mother-in-law, partner, roomer, roomer's wife etc)

Relationship ________
Head ________

3. How old were you on your last birthday?

Age ________
[] under 1 year

4. Race (check one box for each person)

[] White
[] Negro
[] Other

5. Sex (check one box for each person)

[] Male
[] Female

If 17 years old or over, ask:
6. Are you now married, widowed, divorced, separated or never married?
(check one box for each person)

[] Und 17 years
[] Married
[] Widowed
[] Never married
[] Divorced
[] Separated

If 7 years old or over, ask:
7.a What were you doing most of the past 12 months-
(for males): working or doing something else?
(for females): keeping house, working, or doing anything else?

[] Und 17 years
[] Working
[] Keeping house
[] Something else

If "something else" checked, and person is 45 years old or over, ask:
b. Are you retired?

[] Yes
[] No

H
Determine which adults are at home and record this information. Beginning with question 8 you are to interview for himself or herself, each adult person who is at home

[] At home
[] Und 19 yrs
[] Not at home

8. Were you sick at any time last week or the week before? (that is the 2 week period which ended this past Sunday night)?

[] Yes
[] No
a. What was the matter? ________
b. Anything else? ________

9. Last week or the week before did you take any medicine or treatment for any condition (besides...which you told me about)?

[] Yes
[] No
a. For what conditions? ________
b. Anything else? ________

10. Last week or the week before did you have any accidents or injuries?

[] Yes
[] No
a. What were they? ________
b. Anything else? ________

11. Did you ever have an (any other) accident or injury that still bothers you or affects you in any way?

[] Yes
[] No
a. In what way does it bother you? (Record present effects) ________
b. Anything else? ________

12. Has anyone in the family-you, your--etc. had any of these conditions during the past 12 months?
(Read card A, condition by condition; record any conditions mentioned in the column for the person)

[] Yes
[] No
CARD A:
Check list of chronic conditions:
Has anyone in the family had any of these conditions during the past 12 months?

1.Asthma
2. Tuberculosis
3. Chronic bronchitis
4. Repeated attacks of sinus trouble
5. Rheumatic fever
6. Hardening of the arteries
7. High blood pressure
8. Heart trouble
9. Stroke
10. Trouble with varicose veins
11. Hemorrhoids or piles
12. Hay fever
13. Tumor, cyst, or growth
14. Chronic gallbladder or liver trouble
15. Stomach ulcer
16. Any other chronic stomach trouble
17. Kidney stones or chronic kidney trouble
18. Mental illness
19. Arthritis or rhematism
20. Diabetes
21. Thyroid trouble or goiter
22. Any allergy
23. Epilepsy
24. Chronic nervous trouble
25. Cancer
26. Chronic skin trouble
27. Hernia or rupture
28. Prostate trouble

13. Does anyone in the family have any of these conditions?
(Read card B, condition by condition; record any conditions mentioned in the column for the person)

[] Yes
[] No
CARD B:
check list of selected impairments
Does anyone in the family have any of these conditions?

1. Deafness or serious trouble hearing with one or both ears
2. Serious trouble seeing with one or both eyes even when wearing glasses
3. Cleft palate
4. Any speech defect
5. Missing fingers, hand or arm-toes, foot, or leg
6. Palsy
7. Paralysis of any kind
8. Repeated trouble with back or spine
9. Club foot
10. Permanent stiffness or any deformity of the foot, leg, fingers, arm or back
11. Any condition present since birth

14. At the present time do you have any other ailments, conditions, or problems with your health?

[] Yes
[] No
a. What is the condition? (record conditions itself if still present, otherwise record present effects) ________
b. Any other problems with your health? ________

15. a. Have you been in the hospital at any time since ____, a year ago?

[] Yes
[] No

If "Yes" ask:
b. How many times were you in the hospital during that period?

____ No of times.

16. a. Has anyone in the family been a patient in a nursing home, rest home, or any similar place since ____, a year ago?

[] Yes
[] No

If "yes" ask:
b. Who was this? ________

c. How many times were you in a nursing home or rest home during that period?

____No of times.

Interviewer: Examine ages and relationships in Questions 2 and 3 for children one year old or under, then check the appropriate box in Question 17 (a).

17a.

[] Baby (babies) one year or under listed (go to Q 17(b))
[] No baby (babies) one year or under listed (go to Q18)

b. Are birth(s) for baby (babies) and delivery for mother shown in Table II?

[] Yes (go to Q 18)
[] No (Go to Q 17c)

c. Was -- born in the hospital?

[] Yes (go to Q 17 d)
[] No (go to Q 18)

d. When was -- born? (enter month, day, and year).
(If birthdate is since date shown in Qs. 15 and 16, fill one line of Table II for mother and one line for child)

Month ____
Day ____
Year ____

[p.37]

18. a. I have some questions about health insurance. We don't want to include insurance that pays only for accidents, but we are interested in all other kinds. Do you, your --etc, have insurance that pays all part of the bills when you go to the hospital?

[] Yes
[] No

If "Yes" ask:
b. Who is covered by hospital insurance?

(check the "yes" box in 18a. for each person covered) ________

c. What is the name of the plan (or plans)? Any other plans?

Name of plan(s) _______

19a. Excluding insurance that pays only for accidents, do you, your --etc, have insurance that pays all or part of the surgeon's bill of an operation?

[] Yes
[] No

If "Yes" ask:
b. Who is covered by insurance for surgeons' bills?

(check the "Yes" box in 19a for each person covered)________

c. What is the name of the plan (or plans)? Any other plans?

Name of plans ________

20.a. Do you, your --etc have insurance that pays any part of doctors' bill for home calls and office visits?

[] Yes
[] No

If "Yes" ask:
b. Who is covered by insurance for doctor's bills?

(Check the "Yes" box in 20(a) for each person covered) ________

c. What is the name of the plan (or plans)? Any other plans? ________

d. Does it (each plan) pay for some home calls and office visits for most kinds of sickness?

[] Yes
[] No

[] Fem. or und 17 years
If Male and 17 years old or over, ask:
21a. Did you ever serve in the armed forces of the United States?

[] Yes
[] No

If "Yes" ask:
b. Was any of your service during a war or was it peace-time only?

[] Yes
[] Peace-time only

If "War" ask:
c. During which war did you serve?

[] WW II
[] Korean
[] Other

If "Peace-time "only ask:
d. Was any of your service between June 27, 1950 and January 31 1955?

[] Yes
[] No

[] Und 17 yrs.
If 17 years old or over, ask:
22.a. What is the highest grade you attended in school?
(circle highest grade attended or check "None")

[] Elem:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High
[] 1
[] 2
[] 3
[] 4
College:
[] 1
[] 2
[] 3
[] 4
[] 5+
[] None

b. Did you finish the -- grade (year)?

[] Yes
[] No

[] Und. 17 yrs
Ask for all persons 17 years old or over:
23. a. Did you work at any time last week or the week before?

[] Yes
[] No

If "No" ask, both 23b and 23c
b. Even though you did not work last week or the week before do you have a job or business?

[] Yes
[] No

c. Were you looking for work or on layoff from a job?

[] Yes
[] No

NOTE:

1. If "Yes" in Q.23a or Q23b, Q24a-d and Q25 apply to the job or business that the person worked at or had last week or the week before.
2. If "Yes" in Q23c and "No" in 23a and 23b, Q 24a-d and Q25 apply to the person's last full time civilian job.

If "Yes" in Question 23(a), b, or c ask:
24. a. For whom did you work?

Name of employer ________

b. What kind of business or industry was this?

Industry ________

c. What kind of work were you doing?

Occupation ________

Ask only for persons 20 year old or over:
d. Have you been a ____or doing this kind of work for the past three years?

[] und 20 yrs
[] Yes
[] No

25. Class of worker (fill from information in Q 24 a-c; or if not clear, ask additional questions)

[] Private-paid
[] Own
[] Gov't
[] Non-paid

26. Which of these income groups represents your total family income for the past 12 months, that is, yours, your --'s etc?
(show card H). Includes income from all sources, such as wages, salaries, rents from property, social security or retirement benefits, help from relatives etc.

Group ________
CARD H:
Family income during past 12 months:

Group A: Under $500 (including loss)
Group B: $500-$999
Group C: $1,000-$1,999
Group D: $2,000-$2,999
Group E: $3,000-$3,999
Group F: $4,000-$4,999
Group G: $5,000-$$6,999
Group H: $7,000-$9,999
Group I: $10,000 and over

R
[for Q 8-16]
For persons 19 years old or over, show who responded for (or was present during the asking of) Q8-16. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them.

[] Responded for self-entirely
[] Responded for self-partly
Col. ____ was respondent

T
Interviewer: Enter the total number of hospitalizations for each person from Questions 15 and 16, or check the "None" box. Fill one line of table II for each separate stay in the hospital.

Total No.of hospitalizations ________ or
[] None