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

Last name ________
First name ________

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

(List all persons who live here) ________

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

[] Yes (apply household membership rules)
[] No

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

[] Yes (apply household membership rules)
[] No

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

[] Yes (apply household membership rules)
[] No

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?

[] Yes (delete)
[] No

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

Relationship ________
Head ________

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

Age ________
[] White
[] Negro
[] Other
[] M
[] F

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.

[] Und 17
[] Married
[] Widowed
[] Never married
[] Divorced
[] Separated

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?

[] Under 17
[] Working
[] Keeping house
[] Something else

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?

[] At home (interview for self)
[] Under 19
[] Not at home

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)?

[] Yes
[] No

b. What was the matter? ________

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

[] Yes ________
[] No

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

[] Yes
[] No

b. For what condition? ________

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

[] Yes ________
[] No

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

[] Yes
[] No

b. What were they? ________

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

[]Yes ________
[] No

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

[] Yes
[] No

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.

[] Yes
[] No

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?

1. Asthma
2.Chronic bronchitis?
3. Repeated attacks of sinus trouble?
4. Trouble with varicose veins?
5. Hemorrhoids or piles?
6. Hay fever?
7. Tumor, cyst, or growth?
8. Chronic gallbladder or liver trouble?
9. Stomach ulcer?
10. Any other chronic stomach trouble?
11. Kidney stones or chronic kidney trouble?
Have you , your..etc had any of these conditions during the past 12 months?

12. Thyroid trouble or goiter?
13. Any allergy?
14. Chronic nervous trouble?
15. Chronic skin trouble?
16. Hernia or rupture?
17. Prostate trouble?
18. Palsy?
19. Paralysis of any kind?
20. Repeated trouble with back or spine?
21. Cleft palate?
22. Any speech defect?

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

[] Yes
[] No
Card B
Have you, your--etc ever had any of these conditions?

1. Tuberculosis?
2. Hardening of the arteries?
3. High blood pressure?
4. Cancer?
5. Heart trouble?
6. Stroke?
7. Rhematic fever?
8. Arthritis or rhematism?
9. Mental illness?
10. Diabetes?
11. Epilepsy?
Do you, your---etc have any of these conditions?

1. Deafness or serious trouble hearing with one or both ears?
2. Serious trouble seeing with one or both eyes when wearing glasses?
3. Missing fingers, hand or arm--toes, foot or leg?
4. Missing lung or kidney (or breast)?
5. Club foot?
6. Permanent stiffness or any deformity of foot, leg, fingers, arm or back?

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

[] Yes
[] No

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

c. Any other problems with his health?

[] Yes ________
[] No

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

[] Yes
[] No

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

No of times ________

(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)

Month ________
Day ________
Year ________

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.

[] Yes
[] No

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

[] Yes
[] No

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.

[] Responded for self-entirely
[]Responded for self-partly
Person ____ was respondent


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

[] White
[] Negro
[] Other

d. Sex

[] Male
[] Female

e. Marital status

[] Mar
[] Wid
[] Div
[] Sep
[] N.M
[] Under 17

f. Activity status

[] WK
[] KH
[] SE
[] Under 17

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

Elementary ________
High ________
College ________
[] None (go to 3a)

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

[] Yes
[] No

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?

[] Yes (go to 4)
[] No (ask both 3b and 3c)

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

[] Yes
[] No

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

[] Yes (ask 3d)
[] No (go to 3a)

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

[] Looking
[] Layoff
[] Both

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

[] Yes
[] No

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?

Employer ________

b. What kind of business or industry is this ?

Industry ________

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

Occupational ________

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

[] Pvt. paid
[] Gov't Fed
[] Gov't other
[] Own
[] Non-paid
[] Nev-worked

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

[] Yes
[] No (go to 6)

b. Was any of his services during a war?

[] Yes (ask 5c)
[] No (ask 5d)
[] DK (ask 5d)

c. During which was did he serve?

[] Korean
[] Other war
[] DK -ask 5d

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

[] Yes- Korean
[] No

Income: Mark one circle

[] Last rel. person ask 6
[] Not last rel. person (go to next person)

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)

[] A
[] B
[] C
[] D
[] E
[] G
[] H
[] I
[] J
For: Total combined family income during past 12 months

Under $500 (including loss)...Group A
$500-$999....Group B
$1,000-$1,999....Group C
$2,000-$2,999....Group D
$3,000-$3,999....Group E
$4,000-$4,999....Group F
$5,000-$6,999....Group G
$7,000-$9,999....Group H
$10,000-$14,999....Group I
$15,000 and over.... Group J

Washington use
Transcribe codes for item R (respondent)

0-self entirely
1-Self partly
5-Other female family member
6-Other male family member

Family relationship

[] Head 1
[] Head 2+
[] Wife
[] Child
[] Other

Respondent ________

Age of respondent ________

Education of head ________

[] Und 17
[] None

Eyeglasses or contact lenses

[] EG
[] CL
[] Both
[] None
[] Und 3


[] A
[] B
[] C
[] D
[] E
[] F
[] G
[] H
[] J
[] K
[] L
[] M


[] N
[] P
[] R
[] S
[] T
[] U
[] V
[] W
[] X
[] Y
[] Z