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

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

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

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

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

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?

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)

3. How old were you on your last birthday?

4. Race (check one box for each person)

5. Sex (check one box for each person)

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

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?

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

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

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)?

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

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

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

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)

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)

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

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

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

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

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

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

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.

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

c. Was -- born in the hospital?

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)

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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?

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

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

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?

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

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

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

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

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?

[] 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?

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

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

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

[] 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")

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

[] 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?

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?

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

NOTE:

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

b. What kind of business or industry was this?

c. What kind of work were you doing?

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?

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

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.

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.

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.