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hosp


Table II-Hospitalizations

Line number 1:
a. Col No. of person ________
b. Question No ________
Use your Calendar
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 cols (c) and (d). or if not clear ask the questions.
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 conditions 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)
________

l. 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? ____

j. 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 of hospital ________
Street ________
City and state ________

Interviewer:
After completing table II for all persons, carry each condition in col (h) or col (i) back to table I if it does not already appear there and there are "1" or more nights in col (f) or the entry in col (h) or col (i) is an "impairment" or a condition on Card A.

Table A: Accidents and injuries
Line no from table 1 ________
[] Accident happened last week or week before (go to Q3)
1. When did the accident happen?

Year ____
(if 1963, 1964,or 1965 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) ________

3a. 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 (includes 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 palce 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 accidents

Interviewer: Return to table I and complete the rest of this line