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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.



hh_conditionapproach

[p.50]

APPENDIX V. QUESTIONNAIRE: CONDITION APPROACH

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.

Notice: All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes.

US DEPARTMENT OF COMMERCE-
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE


US 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. ________

b. Mailing address: if different from 2a

[] Same as 2a
________
City ____
State ____
Zip Code ________

2c. Special dwelling plan-Name and Sample number

Name ____
Sample no. ____

3. [] Ask [] Do not ask item 3
When was this structure originally built?

[] Before 4-1-60- continue interview
[] After 4-1-60 -go to Q10c, ask if required and end interview

4a. Sample (circle one)

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

Type ____
Code ____

8. Non-interview reason
Type A

[] Ref
[] NOH
[] TA
[] Oth________
Type B
[] VNS
[] VS
[] Usual residence elsewhere
[] Armed Forces
[] Other -specify ________
Type C
[] Dem
[] Mis
[] ES
[] After 4-1-60
[] Oth ________

9. Type of living quarters (mark one circle)

[] Housing unit
[] Other unit

Complete items 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 items 11 and 12
1[] 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 d

b. Does the place you rent have 10 or more acres?

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

c. During the past 12 months did sales of crops, livestock, and other farm products from the 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 the 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

Total rooms ________

14. How many bedrooms are in this--(unit)? If "None" describe in footnotes.

Number of bedrooms ________

15. What is the telephone number here?

Telephone number ________

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

Date and time of calls
Date ____
Time ____
Length of interview
Minutes ____

18. Number of calls at household (mark from item 17) ________

19. Date of completion (enter from item 17)

Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
Day ____

20a. Name of observer. If 20b marked "Yes" ________

b. Was this interview observed?

[] Yes
[] No

21a. Interviewer name ________

b. Interviewer number ________

22. Identification code no. Mark from tab of segment folder. ________

23. Regional office number ________

Washington use
Book number (see item I) _______

Total number of conditions in this HH ________

Total number of hospitalizations in this HH ________

Total number of Doctor visits in this HH ________

Total number of persons in this HH ________

Total persons requiring home care in this household ________