[p.42]
The items below show the exact content and wording of the basic questionnaire used in the nationwide household survey of the US National Health Survey. The actual questionnaire is designed for a household as a unit and includes additional spaces for reports on more than one person, condition, accident, or hospitalization. Such spaces are omitted in this illustration.
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE
U.S HEALTH INTERVIEW SURVEY
1. Book ____ of ____ books
2a. Street address: house no, street, apt. No or other ident.
City ________
State ________
Zip code ________
For area segments, enter:
Line No ________
2b. Mailing address. if different from 2a.
City ________
State ________
Zip code ________
[] Same as 2a
2c. Special dwelling place. name and sample number
Sample No ________
3. [] Ask - When was this structure originally built?
[] After 4-1-60- go to Q 10c, ask if required and end interview
[] Not ask Item 3
[] B-39
[] B-40
[] B-41
[] B-42
[] B-43
4b. PSU ________
b. Seg. Type. Circle
[] B
[] P
[] LSDP
7. Special dwelling place -type and code (mark type code)
Code ________
8. Noninterview reason:
If "other" is marked describe in footnote space.
Type A
[] NOH
[] TA
[] OTH
[] VS
[] LRE
[] AF
[] OTH
[] Mis
[] ESS
[] After 4-1-60
[] OTH
9. Type of living quarters. Mark one circle
[] Other unit
Complete item 10-16 at the end of the interview
10. [] Do not ask item 10- Go to item L
a. [] Ask: Are there any occupied or vacant living quarters besides your own in this building?
[] No
b. [] Ask: Are there any occupied or vacant living quarters besides your own on this floor?
[] No
c. [] Ask: is there any other building on this property for people to live in- either occupied or vacant?
[] No
[] All other - go to 13
11. Do you own or rent this place?
[] Rent- ask 12b
[] Rent free-ask 12a
12a. Does this place have 10 or more acres?
[] No- ask 12d
b. Doe the place your rent have 10 or more acres?
[] No- ask 12d
c. During the past 12 months did sales of crops, livestock and other farm products from this place amount to $50 or more?
[] No (4)
d. During the past 12 months did sales of crops, livestock and other farm products from this place amount to $250 or more?
[] No (5)
13. How many rooms are in this -- (unit)? Count the kitchen but not the bathroom.
Write in and mark .
14. How many bedrooms are in this-unit. If none describe in footnotes.
Write in and mark
15. What is the telephone number here?________
[] No
[] DK
16. Interviewer check item: check questions 22a-22d and 23c on pages 4 and 5 is a home care supplement required.
[] No-leave thank you letter and depart
17. Record of calls at household
[option for 2 entries]
Time ________
Items 18-23 are to be filled after the interview
18. Number of calls at household. Mark from item 17.
[]2
[]3
[]4
[]5
[]6
[]7
[]8
[]9
19. Date of completion. Enter from item 17
[] Feb
[] Mar
[] Apr
[] May
[] June
[] July
[] Aug
[] Sept
[] Oct
[] Nov
[] Dec
20b. Was this interview observed?
[] No
20a. Name of observer. if 20 b marked "Yes" ________
21a. Interviewer name (write-in) ________
21b. Interviewer number ________
22. Identification code no (mark from tab of segment folder) ________
23. Regional office number ________
Book number: see item J ________
Total number of conditions this H.H ________
Total number of hospitalizations this H.H ________
Total number of Doctor Visits this HH ________
Total number of persons this HH ________
Total persons requiring home care this household ________