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Table II-hospitalizations

Line number: 1

a. Col. no of person ____

b. Question No. ____

c. You said that you were in the hospital (once, twice etc) during the past year--
When did you enter the hospital (the last time)?
(enter month, day and year; if exact date not known, obtain estimate)

Month ____
Day ____
Year ____

d. How many nights were you in the hospital?
(if exact number not known accept best estimate)

Nights ____

Complete from entries in columns c and d; or if not clear ask the question.
e. How many of these -- nights were in the past 12 months?

Nights ____

f. How many of these --- nights were last week or the week before?

Nights ____

g. Were you still in the hospital last Sunday night?

[] Yes
[] No

h. For what condition did you enter the hospital--do you know the medical name? ____
(if medical name not known, enter respondent's description)
(entry must show "cause", "kind" and "part of body" in same detail as required in table I)

i. Were any operations performed on you during this stay at the hospital?

[] Yes
[] No
If "yes" ask:
a. What was the name of the operation? ____
b. Any other operations? ____

Ask Col. j- o only for completed hospitalizations ("No" in col. g) and delivery or operation shown in col.b or col i.

j. Was any part of the surgeon's (doctor's) bill paid for by any kind of insurance?

[] Yes (go to col. (l))
[] No (go to col (k))

k. If "No" to col. (j) ask: Do you expect any of the surgeon's (doctor's) bill to be paid for by insurance of any kind?

[] Yes (go to col.(l))
[] No (go to col (o))

l. Did (will) the insurance pay for 1/2 or more of the surgeon's (doctor's) bill?

[] Yes (go to col. m)
[] No (go to col. n)

m. Did (will) the insurance pay for 3/4 or more of the surgeon's (doctor's) bill?

[] Yes
[] No

n. What is the name of the insurance company or plan? (if unable to determine whether or not insurance, describe in footnote space below)

[] Yes insurance
Not insurance (check own):
[] Armed forces medicare
[] Free care
[] Other (specify in footnotes)

o. Ask for all hospitalizations:
What is the name and address of the hospital you were in? (enter full name of hospital, street or highway on which it is located, city and state; if city not known, enter county)

Name ________
Street ________
City and state ________

Table A-Accidents and injuries

Line no from Table 1: ____
[] Accident happened last week or week before (go to Q-3)

1. When did the accident happen?

Year ____
(if 1962, 1963, or 1964 also enter month) Month ____

2. At the time of the accident, what part of the body was hurt? What kind of injury was it? Anything else?

[option for 3 entries for part(s) of body and 3 entries for kind of injury (injuries)]

Part(s) of body ________
Kind of injury (injuries) ________

3. a. Was a car, truck, bus or other motor vehicle involved in the accident in any way?

[] Yes
[] No (go to Q.4)

b. Was more than one motor vehicle involved?

[] Yes (more than one)
[] No

c. Was it (either one) moving at the time?

[] Yes
[] No

4a. Where did the accident happen- at home, or some other place?

1[] At home (inside house)
2[] At home (adjacent premises)
[] Some other place

If "some other place" ask:
b. What kind of place was it?

3[] Street and highway (includs roadway)
4[] Farm
5[] Industrial place (includes premises)
6[] School (includes school premises)
7[] Place of recreation and sports, except at school
8[] Other (specify the place where accident happened) ________

5. Were you at work at your job or business when the accident happened?

1[] Yes
2[] No
3[] While in Armed services
4[] Under 17 at time of accident

Interviewer: return to table I and complete the rest of this line
Footnotes and comments: ________