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[p.43]

APPENDIX III: QUESTIONNAIRE

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 a spaces for reports on more than one person, condition, accident, or hospitalization. Such repetitive spaces are omitted in this illustration.

US DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE

NATIONAL HEALTH SURVEY: FISCAL YEAR 1964

1. Questionnaire ____ of Questionnaires ____

2. a. Address or description of location: include city, zone and state. ________

b. Mailing address if not shown in 2(a) or [] Same as shown in 2(a) ________

c. Name of special dwelling place ________
Code ________

3. Iden. Code ____

4. Reg. office code ____

5. Sub-sample weight ____

6. Sample ____

7. PSU No. ____

8. a. Segment No. ____

b. Segment type ____

9. Serial no. ____

E
If this questionnaire is for an "Extra" unit in a B or NTA segment, enter:

Serial No. of original sample unit ____
Item no. by which found ____

If in NTA segment, also enter for first unit listed on property:
Segment List:

Sheet. No. ____
Line No. ____
L
Ask items 10 and 11 only if "rural box is marked

[] Rural
[] All other (skip to item 12]

10. Do you own or rent this place?

[] Own (ask 11a)
[] Rent (ask 11b)
[] Rent free (ask 11a)

11a. Own or rent free: Does this place have 10 or more acres?

[] Yes
[] No

b.Rent: Does this place you rent have 10 or more acres?

[] Yes
[] No

c. During the past 12 month did sales of crops, livestock and other farm products from the place amount to $50 or more?

[] Yes
[] No

d. During the past 12 months did sales of crops, livestock and other farm products from the place amount to $250 or more?

[] Yes
[] No

12. Type of living quarters (check one box)

[] Housing unit
[] Other unit

All segments (ask if item 2a address identifies a single-unit structure).
13.Are there any occupied or vacant living quarters besides your own-

in the basement?
[] Yes -- S ____ L ____
[] No
on this floor?
[] Yes -- S ____ L ____
[] No
on any other floor of this building?
[] Yes -- S ____ L ____
[] No
(fill table X for each quarters not listed).

All segments (ask if item 2a identifies entire floor or unnumbered part of floor in a multi-unit structure)?
14. Are there any occupied or vacant living quarters besides your own-
If item 2a identifies entire floor

--on this floor?
[] Yes--S ____ L ____
[] No

If item 2a idenifies part of floor, specify part

--in the -- of this floor?
[] Yes--S ____ L ____
[] No
(fill table X for each quarters not listed)

TA and NTA segments (ask at all units except apartment houses)
15. Is there any other building on this property for people to live in-either occupied or vacant?

[] Yes-- S ____ L ____
[] No
(fill table X for each quarters not listed)

16. What is the telephone number here?

Telephone no. ________ or
[] No telephone
B
Important: to interviewer
Check table I for eye conditions or vision problems (including cataracts and glaucoma) for persons 6 years old or over, then answer the question below.
Has anyone in this household, 6 years old or over, been reported as having an eye condition or vision problem?

[] Yes (fill one line of table B on page 8 for each such person)
[] No (leave "thank you" letter and depart)

17. Record of calls at household
Item 1

Entire household
Date ____
Time ____
Com. ____
Record of return calls for individual respondents
Col. No ____
Date ____
Time ____
Com. ____

18. Reason for noninterview
Type A
Reason:

[] Refusal (describe in footnotes)
[] No one at home - repeated calls
[] Temporarily absent
[] Other (specify)
Type B
Reason:

[] Vacant-non-seasonal
[] Vacant -seasonal
[] Usual residence elsewhere
[] Armed forces
[] Other (specify)
Type C
Reason:

[] Demolised
[] In sample by mistake
[] Elimitated in sub-sample
[] Other (specify)
Type Z
Interview not obtained for:

Cols. ____ ____ ____ because ________

19. Signature of interviewer ________

20. Code ____

Footnotes and comments: ________

Table X - Living quarters determinations at listed Address

1. Line number 1

2. Questionnaire item no. ____

3. Are these (specify location) quarters for more than one group of people?

a[] Yes (fill one line for each group)
b[] No

4. Location of unit

(examples: basement, 2nd floor) ________
Use or characteristics
5. Occupied: do the occupants of these (specify location) quarters live and eat with any other group of people?

a[] Yes
b[] No

All quarters: do these (specify location) quarters have:
6. Direct access from the outside or through a common hall?

a[] Yes
b[] No

7. A kitchen or cooking equipment for exclusive use?

a[] Yes
b[] No
Classification:
8. Not a separate unit (add ocupants to this questionnaire) ________

9.Fill separate questionnaire and interview

a[] HU
b[] Other unit

If HU in B segment ask:
10. In what year were these (specify location) quarters created? ________
(if 1959 or 1960, also specify "F" if first half or "L" if last half)

11. (if before July 1960) What was the name of the household head of these quarters on April 1, 1960? ________

12. Remarks ________