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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.




1. Person number ________

Enter month, day, year; if the exact date is not known, obtain the best estimate. Use your calender.
You said that --was in the (hospital/nursing home) during the past year:
2. When did -- enter the (hospital/nursing home) (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/nursing home)?

Total nights in hospital-nursing home ________

Complete question 4 from entries in questions 2 and 3; if not clear ask the questions.
4a. How many of these -- nights were in the past 12 months?

Nights past 12 months ________

Do not include any nights in interview week.
b. How many of these -- nights were last week or the week before?

Nghts past 2 weeks ________

Use your calender.
c. Was -- still in the (hospital/nursing home) last Sunday night for this hospitalization (stay)?

[] Yes
[] No

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/nursing home)-do you know the medical name?
For delivery ask: wasthis a normal delivery?
For newborn ask: was the baby normal at birth?
If "No" ask what was the matter?
Record in condition box.

Condition ________
Cause _______
Kind ________
Part of body ________

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

[] 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 or nursing home; the street or highway on which it is located and the city and state; if the city is not known, enter the county.
What is the name and address of the (hospital/nuring home)?

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


Ask if "No" marked in question 4c.
8. What was the total amount of the (hospital/nursing home) bill for this stay?
Do not include doctor's or surgeons' bills.

Dollars ________
Cents ________

9a. Did (will) health insurance pay any part of this bill?

[] Yes
[] No -go to 10

b. What is the name of the insurance plan?

Name of insurance plan ________

c. Did (will) any other health insurance plan pay part of this (hospital/nursing home) bill?
If "Yes" reask 9b.

[] Yes
[] No

For each health insurance plan named ask:
d. What was (will-be) the amount paid by (name of place)?

Dollars ________
Cents ________

Enter total amount paid by health insurance in Line A.
Enter any amount paid by social security medicare in line B.

10a. Who paid (will pay) the (remainder of the) hospital bill? Mark each category mentioned.

A[] Health insurance (all plan -exclude Medicare)
B[] Social security medicare
C[] Self and/or family
D[] Relative not in household
E[] Friend
F[] Kerr Mills or other Fed. Plans
G[] Armed forces medicare
H[] State or Local welfare agency
I[] Other specify

b. Did any other person or agency pay any other part of the hospital bill?

[] Yes -ask 10c
[] No-go to 10d

c. Who was this? Mark each category mentioned.

A[] Health insurance (all plan -exclude Medicare)
B[] Social security medicare
C[] Self and/or family
D[] Relative not in household
E[] Friend
F[] Kerr Mills or other Fed. Plans
G[]Armed forces medicare
H[] State or Local welfare agency
I[] Other specify

d. What was the amount paid by --?
Enter amount paid opposite appropriate category.
Total of above- include amount paid by health insurance.

Dollars ________
Cents ________

Add amounts entered (include any amount paid by health insurance) and enter in total box, then mark one of the following boxes.

[] Total amount paid (to be paid) agrees with amount of hospital bill- go to Q 11
[] Total amount paid (to be paid) does not agree with amount of hospital bill. Resolve difference with respondent.

Ask question 11-13 if person is 55 years old or over. Mark one circle

[] Under 55 - go to 14
[] 55 or over -ask 11a

11a. When -- left (name of hospital/nursing home). did he return home or go some other place?

[] Home - go to question 12
[] Some other place- ask question 11b

b. What kind of place did-- go to?

Specify ________

If the place in 11b is a hospital, nursing home or a similar place, was a hospital page filled for that stay? Mark one box.

[] Hospital page filled-stop
[] Hospital page not filled- fill hosp page for unreported stay

12. After leaving the (hospital/nuring home) how many days did -- have to remain in bed all or most of the day? Mark entry.

Days ________
[] Still in bed - go to 14
[] None

13. (Altogether) how many days was -- confined to the house after returning home from the (hospital/nursing home)? Mark entry.

Days ________
[] Still confined to house
[] None

14. Note to interviewer
If the condition in question 5 or 6 is on card A (A-1, A-2) or B (B-1, B-2) or there is "1" or more nights in question 4b, the condition must have a completed condition page. If the condition does not have a conditions page, fill one after completing all required hospital pages

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 or 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. Palsy?
17. Paralysis of any kind?
18. Repeated trouble with back or spine?
19. Cleft palate?
20. Any speech defect?
21. Hernia or rupture?
22. Prostate trouble?

Have you, your-- etc ever had any of these conditions?

1. Tuberculosis?
2. Emphysema?
3. Hardening of the arteries?
4. High blood pressure?
5. Cancer?
6. Heart trouble?
7. Stroke?
8. Rhematic fever?
9. Arthritis or rheumatism?
10. Mental illness?
11. Diabetes?
12. 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 even 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?