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hh

[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.

US DEPARTMENT OF COMMERCE
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:

Sheet No. ________
Line No ________

2b. Mailing address. if different from 2a.

________
City ________
State ________
Zip code ________
[] Same as 2a

2c. Special dwelling place. name and sample number

Name ________
Sample No ________

3. [] Ask - When was this structure originally built?

[] Before 4-1-60 -continue interview
[] After 4-1-60- go to Q 10c, ask if required and end interview
[] Not ask Item 3

4a. Sample - cirlce one

[] B-38
[] B-39
[] B-40
[] B-41
[] B-42
[] B-43

4b. PSU ________

5a. Segment number ____

b. Seg. Type. Circle

[] A
[] B
[] P
[] LSDP

6. Serial Number ________

7. Special dwelling place -type and code (mark type code)

Type ________
Code ________

8. Noninterview reason:
If "other" is marked describe in footnote space.
Type A

[] Ref
[] NOH
[] TA
[] OTH
Type B
[] VNS
[] VS
[] LRE
[] AF
[] OTH
Type C
[] Dem
[] Mis
[] ESS
[] After 4-1-60
[] OTH

9. Type of living quarters. Mark one circle

[] Housing unit
[] 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?

[] Yes -fill table X
[] No

b. [] Ask: Are there any occupied or vacant living quarters besides your own on this floor?

[] Yes-fill table X
[] No

c. [] Ask: is there any other building on this property for people to live in- either occupied or vacant?

[] Yes - fill table X
[] No

Item L

[] Rural- Ask item 11 and 12
[] All other - go to 13

11. Do you own or rent this place?

[] Own-ask 12a
[] Rent- ask 12b
[] Rent free-ask 12a

12a. Does this place have 10 or more acres?

[] Yes -ask 12c
[] No- ask 12d

b. Doe the place your rent have 10 or more acres?

[] Yes -ask 12c
[] 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?

[] Yes (2)
[] 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?

[] Yes (3)
[] No (5)

13. How many rooms are in this -- (unit)? Count the kitchen but not the bathroom.
Write in and mark .

Total rooms ________

14. How many bedrooms are in this-unit. If none describe in footnotes.
Write in and mark

No. of bedrooms ________

15. What is the telephone number here?________

[] Yes
[] No
[] DK

16. Interviewer check item: check questions 22a-22d and 23c on pages 4 and 5 is a home care supplement required.

[] Yes -fill home care supplement
[] No-leave thank you letter and depart

17. Record of calls at household

[option for 2 entries]

Date and time of call
Date ________
Time ________
Length of interview
Minutes ________

Items 18-23 are to be filled after the interview
18. Number of calls at household. Mark from item 17.

[] 1
[]2
[]3
[]4
[]5
[]6
[]7
[]8
[]9

19. Date of completion. Enter from item 17

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

20b. Was this interview observed?

[] Yes
[] 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 ________

Washington use

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 ________