[p.43]
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.
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 ________
b. Segment type ____
E
If this questionnaire is for an "Extra" unit in a B or NTA segment, enter:
Item no. by which found ____
If in NTA segment, also enter for first unit listed on property:
Segment List:
Line No. ____
L
Ask items 9 and 10 only if "rural box is marked
[] All other (skip to item 12]
9. Do you own or rent this place?
[] Rent (ask 11b)
[] Rent free (ask 11a)
10a. Own or rent free: Does this place have 10 or more acres?
[] No
b. Rent: Does this place you rent have 10 or more acres?
[] No
c. During the past 12 month did sales of crops, livestock and other farm products from the place amount to $50 or more?
[] No
d. During the past 12 months did sales of crops, livestock and other farm products from the place amount to $250 or more?
[] No
11. Type of living quarters (check one box)
[] Other unit
All segments (ask if item 2a address identifies a single-unit structure).
12.Are there any occupied or vacant living quarters besides your own-
[] No
[] No
[] 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)?
13. Are there any occupied or vacant living quarters besides your own-
If item 2a identifies entire floor
[] No
If item 2a idenifies part of floor, specify part
[] No
(fill table X for each quarters not listed)
TA and NTA segments (ask at all units except apartment houses)
14. Is there any other building on this property for people to live in-either occupied or vacant?
[] No
(fill table X for each quarters not listed)
15. What is the telephone number here?
[] No telephone
D
Important: to interviewer
Check table I for diabetes. Enter the column numbers of all person who have been reported as having diabetes. If no persons with diabetes, check the "None" box.
(Fill Diabetes Supplement for EACH such person)
[] None (leave "thank you" letter and depart)
17. Record of calls at household
Item 1
Time ____
Com. ____
Date ____
Time ____
Com. ____
18. Reason for noninterview
Type A
Reason:
[] No one at home - repeated calls
[] Temporarily absent
[] Other (specify)
Reason:
[] Vacant -seasonal
[] Usual residence elsewhere
[] Armed forces
[] Other (specify)
Reason:
[] In sample by mistake
[] Elimitated in sub-sample
[] Other (specify)
Interview not obtained for:
19. Signature of interviewer ________
Footnotes and comments: ________
Table X - Living quarters determinations at listed Address
2. Questionnaire item no. ____
3. Are these (specify location) quarters for more than one group of people?
b[] No
Use or characteristics
5. Occupied: do the occupants of these (specify location) quarters live and eat with any other group of people?
b[] No
All quarters: do these (specify location) quarters have:
6. Direct access from the outside or through a common hall?
b[] No
7. A kitchen or cooking equipment for exclusive use?
b[] No
Classification:
8. Not a separate unit (add ocupants to this questionnaire) ________
9.Fill separate questionnaire and interview
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? ________