hosp

[p.43]

1. Person number ________

Enter month, day, year; if exact date is not known, obtain the best estimate.
Use your calendar
You said that -- was in the hospital (once, twice etc) during the past year:
2. When did -- enter the hospital (the last time)?

Do not include any nights in interview week. If the exact number is not known, accept the best estimate.
3. How many nights was -- in the hospital?

Complete question 4 from entries in questions 2 and 3; if not clear, ask the questions. Do not include any nights in interview week. Use your calender.
4a. How many of these --nights were in the past 12 months?

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

c. Was -- still in the hospital last Sunday night for this hospitalization?

Ask for all hospitalization.
If medical name not known, enter an adequate description.
Entry must show cause, kind, and part of body in same detail as required for the condition page.
5. For what condition did -- enter the hospital do you know the medical name?
For delivery, ask: was this a normal delivery?
For newborn: Was the baby normal at birth?
If "No" ask: what was the matter? (record in condition box)

If name of operation is not known, describe what was done.
6a. Were any operations performed on -- during this stay at the hospital?

b. What was the name of the operation?

c. Any other operations?

Enter the full name of the hospital, the street or highway on which it is located and the city and state; if the city is not known, enter the country.
7. What is the name and address of the hospital?

If the condition in question 5 or 6 indicates that an accident or injury was involved, fill question 8-11

8a. Did the accident happen during the past 2 years or before that time?

b. When did the accident happen?
Enter month and year, mark one circle.

9a. Was a car, truck, bus, or other motor vehicle involved in the accident in any way?

b. Was more than one vehicle involved?

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

10. Where did the accident happen?

11. Was -- at work at this job or business when the accident happened?

Washington use

Month:

Day ________

Year ________

Nights ________

Q. No

Diag: ________

Diagnosis surgically treated ________

Service ________

Ownership ________

When accident happened ________

Oth Acc

IC or Dum. code ________

Note to interviewer: If the condition in question 5 or 6 is on Card A or B or there are "1" or more nights in question 4b, the condition must have a completed condition page. If the condition does not have a condition page, fill one after completing all required hospitalization pages