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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)?

Month ________
Day ________
Year ________ (make sure the year is correct)

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?

Total nights in 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?

Nights in past 12 months ________

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

Nights past 2 weeks ________

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

[] Yes
[] No

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)

Condition ________

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

[] Yes
[] No (go to 7)

b. What was the name of the operation?

Operation ________

c. Any other operations?

[] Yes (Describe above)
[] No

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?

Name of hospital ________
Address ________
City (or county) ________
State ________

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?

[] During the past 2 years
[] Before 2 years (6)- go to 9a

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

Month ________
Year ________
[] Last week (0)
[] Week before (1)
[] 2 Week-3 months (2)
[] 3-12 months (4)
[] 1-2 years (5)

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

[] Yes
[] No (go to 10)

b. Was more than one vehicle involved?

[] Yes
[] No

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

[] Yes
[] No

10. Where did the accident happen?

[] At home (inside house)
[] At home (adjacent house)
[] Street and highway (including roadway)
[] Farm
[] Industrial place (includes premises)
[] School (includes school premises)
[] Place of recreation and sports (except school)
[] Other (specify place where accident happened) Specify place ________

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

[] Yes
[] No
[] Under 17 at time
[] While in the Armed Forces

Washington use


[] Jan
[] Feb
[] Mar
[] Apr
[] May
[] June
[] July
[] Aug
[] Sept
[] Oct
[] Nov
[] Dec

Day ________

Year ________

Nights ________

Q. No

[] 13
[] 14
[] Other

Diag: ________

Diagnosis surgically treated ________

Operation 1 ________
Operation 2 ________
Operation 3 ________

Service ________

Ownership ________

When accident happened ________

Oth Acc

[] T-Mis
[] Other

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