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[p.43]


PERSON

1a. What is the name of the head of this household?

First name ________
Last name ________

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

First name ________
Last name ________

c. I have listed (read names). Is there anyone else staying here now.

[] Yes
[] No

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

[] Yes
[] No

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

[] Yes
[] No

f. Are any of the persons in this household on full-time active duty in the armed forces?
If "yes" delete.

[] Yes
[] No

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

[] Relationship: Head
Relationship ________
Age _________

3. Person number First column should have person 01. Second column person 02 etc

Person no. ________

4a. How old was -- on his last birthday. Write in next to "relationship" and mark

Age ________

b. Sex (mark without asking unless sex is not obvious from name)

[] Male
[] Female

c. Race (mark without asking)

[] White
[] Negro
[] Other

If 17 years old or over, ask:
5. Is -- now married, widowed, divorced, separated, or never married?

[] Mar
[] Wid
[] Div
[] Sep
[] NM
[] Und 17

If 17 years old or over, ask:
6. 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?

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

If "SE" marked in Q.6 and person is 45 years old or over, ask:
7. Is -- retired?

[] Yes
[] No

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

[] Under 19
[] At home
[] Not 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 calender to respondent and ask 8a.
8a. Was --sick at any time last week or the week before (the 2 weeks shown on that calender)?

[] Yes
[] No

b. What was the matter? _________

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

[] Yes
[] No

9a. 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

10a. 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

11a. Did -- ever have an (any other) accident or injury that still bothers him or affects him in any way?

[] Yes
[] No

b. In what way does it bother him? Record present effects. _________

12. Open you flashcard booklet to Card A and read both sides of card A (A-1, A-2) condition by condition; record in his column any conditions mentioned for the person.

[] Yes
[] No

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?

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 liver?
10. Any other chronic stomach trouble?
11. Kidney stones or chronic kidney trouble?
A-2:
Have you, your---etc, had any of these conditions During the past 12 months?

12. Thyroid trouble or goiter?
13. Any allergy?
14. 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?

13. Turn to card B and read both sides of Card B (B-1, B-2) condition by condition; record in his column any conditions mentioned for the person.

[] Yes
[] No

CARD B:
B-1:
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. Rheumatic fever?
9. Arthritis or rheumatism?
10. Mental illness?
11. Diabetes?
12. Epilepsy?
B-2:
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?

14a. 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 this health?

[] Yes
[] No

R
(Q 8-14)
For person 19 years old or over, show who responded for (or was present during the asking of Q 8-11). 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

[p.44]

15a. Has -- been in a hospital at any time since -- a year ago?

[] Yes
[] No

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

Time ________

16a. Has anyone in the family been in a nursing home, convalescent home, rest home or similar place since -- a year ago?

[] Yes
[] No

If "Yes" ask:
b. Who? ________

For each person reported in 16b, ask:
c. How many times was -- in a nursing home or similar place during that period?

Times ________

Examine ages in question 1 for babies 1 year old or under. For each child 1 year old or under, under 17a.
17a. When was -- born? If on or after the date stamped in 15a, ask 17b.

Month ________
Day ________
Year ________

b. Was -- born in a hospital?
If "Yes" and no hospitalizations entered in his column enter "1" in 15. If "Yes" and a hospitalization is reported for the mother and baby ask 17c.

[] Yes
[] No

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

[] Yes
[] No

These next questions are about recent visits to or from a medical doctor.
18. During the past 2 weeks (the 2 weeks outlined in red on that calendar). How many times has -- seen a doctor either at home or at a doctor's office or clinic?

[] None
Dr. Visits ________

19a. (Besides those visits) During that 2 week period has anyone in the family been to a doctor's office or clinic for shots, X-rays, tests, or examinations?

[] Yes
[] No

If "Yes" ask:
b. Who was this? ________

c. Any one else?
Mark "Yes" in person column.

[] Yes
[] No

For each "Yes" marked ask:
d. How many telephone calls were made to get medical advice about--?

Telephone calls to Dr. ________

Visits reported in questions 18-20 for this person.
Mark here.

[] Visits rep'd in Q 18-20 (go to 21b)

If no visits reported in questions 18-20 ask:
21a. About how long has it been since -- saw or talked to a doctor>
Estimate is acceptable. If less than 1 year, mark appropriate circles; if more than 1 year. Mark number of whole years.

[] Year ________
[] During past 2 weeks/not previously reported
[] 2 weeks-6 months
[] 7-11 months
[] DK
[] Never

If the last visit was within the past 12 months ask:
b. In total, about how many times has -- seen or talked to a doctor during the past 12 months?

[] Times ________
[] DK
[] Never

If person is 55 years old or over ask:
The following questions refer to different kinds of personal care some people need at home:

[] Under 55 (stop)
[] 55 or over (ask 22a)

22a. Does -- need any help in bathing, dressing or putting on his shoes?

[] Yes (stop)
[] No
[] DK

b. Does -- need any help at home with injections, shots, or other treatments?

[] Yes (stop)
[] No
[] DK

c. Does -- need any one's help when walking up stairs or getting from room to room?

[] Yes (stop)
[] No
[] DK

d. Does -- need any help at all in caring for himself?

[] Yes (stop)
[] No
[] DK

23a. During the past 12 months, has -- received any care at home from a nurse?

[] Yes (ask 23b and c)
[] No (stop)
[] DK

b. During this 12 months period, about how many visits did a nurse make to care for --?
________

c. Were any of these visits during the past 2 weeks?

[] Yes
[] No
[] DK

[p.50]

Ask for all person 17 years old or over:
24a.What is the highest grade (year) --attended in school?

[] Elem ________
[] High school ________
[] College ________
[] Under 17

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

[] Yes
[] No

Ask for all persons 17 years old or over:
25a. Did -- work at any time last week or the week before?
For females add: not counting work around the house?

[] Yes -go to 26a
[] No-ask both b and c

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 d
[] No- omit d

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

[] Looking
[] Layoff
[] Both

If "Yes" in 25a only, questions 26a through 26d apply to this person's Last full time civilian job.
Ask for all persons with a "Yes" in 25a, 25b or 25c
26a. Who does (did) -- work for?

Employer ________

b. What kind of business or industry is this?

Industry ________

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

Occupation ________

Fill 26d from entries in 26a-26c; if not clear ask;
d. Class of worker.

[] Prepaid
[] Gov't-fed
[] Gov't-other
[] Own
[] Non-paid
[] Nev-worked

Ask for all males 17 years old or over
27a. Did --ever serve in the armed forces of the united states?

[] Yes
[] No - go to 28

b. Was any of his service during a war?

[] Yes-stop
[] No
[] DK

If "No" or "DK" in 27b, ask:
c. Was any of his service between June 27, 1950 and January 31, 1955?

[] Yes -stop
[] No
[] DK

If "No" or "DK" in 27c, ask:
d. Was any of his service after January 31, 1955?

[] Yes
[] No
[] DK

28. Which of these income groups represents your total combined family income for the past 12 months -that is yours, your--'s etc? Show card I. 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 in each related person's column.

[] A
[] B
[] C
[] D
[] E
[] F
[] G
[] H
[] I
[] J

Washington use:

Transcribe codes for item R (respondent)

0-Self entirely
1-Self partly
2-Spouse
3-Mother
4-Father
5-Other female family member
6-Other male family member
7-Other

Respondent ________

Age of respondent ________

Family respondent

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

Education of head

[]Und 17
[] None

Industry

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

Occupation

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