person

[p.40]

1a. What is the name of the head of this household? (enter name in column for Person 01)

b. What are the names of all other persons who live here?

c. I have listed (read names ). Is there anyone else staying here now such as friends, relatives, or roomers?

d. Have I missed anyone who usually lives here but is now away from home?

e. Do any of the people in this household have a home anywhere else?

If any adult males listed, ask:
f. Are any of the persons in this household now on full-time active duty with the armed forces of the United States?

2. How is -- related to __ (head of household)?

3. How old was -- on his last birthday? (also mark race and sex)

If 17 years old or over, ask:
4. Is -- now married, widowed, divorced, separated, or never married? (mark one box for each group)
If persons under 17 are or have been married mark the "Und 17" box and give marital status in a footnote.

If 17 years old or over, ask:
5. What was -- doing most of the past 12 months-
(for males) working or doing something else?
(for females) keeping house, working or doing something else?

H
If related persons 19 years old or over are listedin addition to the respondent say:
We would like to have all adults who are at home take part in the interview. Is your --etc, at home now?
If other eligible respondents are at home, ask:
Would you please ask --, -- etc to join us?

This survey covers all kinds of illness. These first questions refer to last week and the week before, that is, the 2 week period outlined in red on this calender. (hand calendar)
6a. Was -- sick at any time last week or the week before? (the 2 weeks shown on that calendar)?

b. What was the matter? ________

c. Did -- have anything else during the 2 week period?

7a. Last week or the week before, did -- take any medicine or treatment for any condition (besides..which you told me about)?

b. For what condition? ________

c. Did --take any medicine for any other condition?

8a. Last week or the week before did -- have any accidents or injuries?

b. What were they? ________

c. Did -- have any other accidents or injuries during that 2 week period?

9a. Did --ever have an (any other) accident or injury that still bothers him or affects him in anyway?

b. In what way does it bother him? (Record present effects) ________

Open your flashcard booklet to card A
10. Read both sides of card A, condition by condition; record in his column any conditions mentioned for the person.

CARD A:
A-1:
Now I'm going to read a list of conditions- please tell me if you, your--etc have had any of these conditions During the past 12 months?

A-2:
Have you , your..etc had any of these conditions during the past 12 months?

Turn to Card B:
11. Read both sides of card B, condition by condition; record in his column any conditions mentioned for the person.

Card B
B-1:
Have you, your--etc ever had any of these conditions?

B-2:
Do you, your---etc have any of these conditions?

12a. Does -- have any other ailments, conditions or problems with his health?

b. What is the condition?
(Record condition itself if still present; otherwise record present effects)________

c. Any other problems with his health?

13a. Has -- been in a hospital at any time since ---a year ago?
Include stays in nursing homes, rest homes or similar places.

If "Yes" ask:
b. How many times was -- in a hospital during that period?

(Examine ages in question 3 for babies 1 year old or under. For each child 1 year old or under, ask 14a)
14a. When was --born? (if on or after the date stamped in 13a, ask 14b)

b. Was -- born in a hospital?
If "Yes" and no hospitalizations entered in his column, enter "1" in 13b.
If "Yes" and a hospitalization is reported for the mother and baby, ask 14c.

c. Is this hospitalization included in the number you gave me for --?
(if "No" correct entry for mother and baby)

R
(Q6-14)
For persons 19 years old or over, show who responded for (or was present during the asking of) Q6-14. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them. If eligible respondent is "at home" but did not respond for self, enter the reason in a footnote.

[p.46]

Write in person number and age below
Person No ________

Age ________

If 17 or over, ask question 2.
If under 17 , go to question 6 (income)

Transcription items to be marked for all persons after the interview

1a. Person no ________

b. Age ________

c. Race

d. Sex

e. Marital status

f. Activity status

Ask for all persons 17 years old or over.
2a. What is the highest grade (year) --attended in school?

b. Did --finish the --grade (year)?

Ask for all persons 17 years old or over.
3a. Did -- work at any time last week or the week before?
(for females add) not counting work around the house?

b. Even though -- did not work during those 2 weeks, does he have a job or business?

c. Was he looking for work or on layoff from a job?

d. Which? looking for work or on layoff from a job?

If male 45 years old or over and all "No's" in 3a-3c ask:
e. Is he retired?

Ask for all persons with a "Yes" in 3a, 3b, and 3c. If "Yes" in 3c only, questions 4a through 4d apply to this person's last full time civilian job.
4a. Who does (did) -- work for?

b. What kind of business or industry is this ?

c. What kind of work is (was ) he doing?

Fill 4d from entries in 4a-4c; if not clear ask:
d. Class of worker:

Ask for all males 17 years old or over:
5a. Did -- ever serve in the Armed Forces of the United States/

b. Was any of his services during a war?

c. During which was did he serve?

d. Was any of his service betweem June 27, 1950 and January 31, 1955?

Income: Mark one circle

6. Which of these income groups represents your total combined family income for the past 12 months- that is, your's , your--'s etc? Show card J. Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rents from property and so forth. (Mark income group on each person page for related members)

CARD J
For: Total combined family income during past 12 months

Washington use
Transcribe codes for item R (respondent)

Family relationship

Respondent ________

Age of respondent ________

Education of head ________

Eyeglasses or contact lenses

Ind

Occ.