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)?
Year ________ (make sure the year is correct)
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)
 No (go to 7)
b. What was the name of the operation?
c. Any other operations?
City (or county) ________
 Before 2 years (6)- go to 9a
 Last week (0)
 Week before (1)
 2 Week-3 months (2)
 3-12 months (4)
 1-2 years (5)
 No (go to 10)
 At home (adjacent house)
 Street and highway (including roadway)
 Industrial place (includes premises)
 School (includes school premises)
 Place of recreation and sports (except school)
 Other (specify place where accident happened) Specify place ________
 Under 17 at time
 While in the Armed Forces
Diagnosis surgically treated ________
Operation 2 ________
Operation 3 ________
When accident happened ________
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