hosp

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)

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

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?

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

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

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?

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?

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?

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

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

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

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)

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?

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)]

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

b. Was more than one motor vehicle involved?

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

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

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

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

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