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[p.39]

APPENDIX III: QUESTIONNAIRE

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 spaces for reports on more than one person, condition, accident, or hospitalization. Such spaces are omitted in this illustration.

US DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE


NATIONAL HEALTH SURVEY

1a. Street address (enter description of location if no street address)

________
City ________
State ________

1b. Mailing address (if different from 1a)

________
City ________
State ________

1c. Name of special dwelling place ________
code ________

2. PSU ____

3. Segment No. ____

4. Serial No. ____

5. Sample ____

6. Record of calls at household
Visits: 1st

Entire household
Mo/Day ____
Time ____
Record of return calls for individual respondents

[option for up to 2 entries]
Person No ____
Mo/day ____
Time ____

Visits: 2nd

Entire household
Mo/Day ____
Time ____
Record of return calls for individual respondents

[option for upto 2 entries]
Person No ____
Mo/day ____
Time ____

Visits: 3rd

Entire household
Mo/Day ____
Time ____
Record of return calls for individual respondents

[option for upto 2 entries]
Person No ____
Mo/day ____
Time ____

Visits: 4th

Entire household
Mo/Day ____
Time ____
Record of return calls for individual respondents

[option for upto 2 entries]
Person No ____
Mo/day ____
Time ____

Visits: 5th

Entire household
Mo/Day ____
Time ____
Record of return calls for individual respondents

[option for upto 2 entries]
Person No ____
Mo/day ____
Time ____

7. Reason for noninterview
Type A
Reason:

[] Refusal (describe in footnotes) (REF)
[] No one at home- repeated calls (NOH)
[] Temporarily absent (TA)
[] Other (specify) (OTH)
Type B
Reason:

[] Vacant - nonseasonal (VNS)
[] Vacant- seasonal (VS)
[] Usual residence elsewhere (URE)
[] Armed Forces (AF)
[] Other (specify) (OTH)
Type C
Reason:

[] Demolished (DEM)
[] In sample by mistake (MIS)
[] Eliminated in subsample (ESS)
[] Built after April 1 1960
[] Other (specify) (OTH)

8. Signature of interviewer ________

9. Code ____

10. Observed?

[] Yes - Name of observer ________
[] No

E
(if this questionnaire is for an 'Extra' unit in B or NTA segment, enter)

Serial No of original sample unit____
Item No by which found ____

If in NTA segment, also enter for First unit listed on property
Segment list

Sheet No. ________
Line no. ________

11. Table X- living quarters determinations at listed address

1. Line number

2. Questionnaire item no. ________

3. Are these (Specify location) quarters for more than one group of people?

a[] Yes (fill one line for each group)
b[] No

4. Location of unit

(examples: basement, 2nd floor) ________

Use or characteristics
5. Occupied: Do the occupants of these (specify location) quarters live and eat with any other group of people?

a[] Yes
b[] No

All quarters: Do these (specify location) quarters have:
6. Direct access from the outside or through a common hall?

a[] Yes
b[] No

7. A kitchen or cooking equipment for exclusive use?

a[] Yes
b[] No

Classification
8. Not a separate unit (add occupants to this work sheet) ________

9. Fill separate worksheet and interview

a[] HU
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 or L) ________

11. (if before july 1960) What was the names of the household head of these quarters on April 1 1960? ________

12. Remarks: ________