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)
d. How many nights were you in the hospital?
(if exact number not known, accept best estimate)
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?
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 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?
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)
City and state ________
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?
(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)]
Kind of injury (injuries) ________
3a. Was a car, truck, bus or other motor vehicle involved in the accident in any way?
 No (go to Q. 4)
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?
2 At home (adjacent premises)
 Some other place
If "some other place" ask:
b. What kind of place was it?
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?
3 While in Armed services
4 Under 17 at time of accidents
Interviewer: Return to table I and complete the rest of this line