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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.
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE
US HEALTH INTERVIEW SURVEY
2a.Street address- house no, street, apt. No. or other ident.
City ________
State ________
ZIP code ________
For area segments enter:
Line No. ________
b. Mailing address: if different from 2a
________
City ____
State ____
Zip Code ________
2c. Special dwelling plan-Name and Sample number
Sample no. ____
3. [] Ask [] Do not ask item 3
When was this structure originally built?
[] After 4-1-60 -go to Q10c, ask if required and end interview
[] B-39
[] B-40
[] B-41
[] B-43
b. SEG type (circle)
[] B
[] P
[] LSDP
7. Special dwelling place- type and code
Code ____
8. Non-interview reason
Type A
[] NOH
[] TA
[] Oth________
[] VS
[] Usual residence elsewhere
[] Armed Forces
[] Other -specify ________
[] Mis
[] ES
[] After 4-1-60
[] Oth ________
9. Type of living quarters (mark one circle)
[] 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?
[] 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
1[] 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 d
b. Does the place you 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 the place amount to $50 or more?
[] 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?
[] No (5)
13. How many rooms are in this -- (unit)? Count the kitchen but not the bathroom
14. How many bedrooms are in this--(unit)? If "None" describe in footnotes.
15. What is the telephone number here?
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
Time ____
18. Number of calls at household (mark from item 17) ________
19. Date of completion (enter from item 17)
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
20a. Name of observer. If 20b marked "Yes" ________
b. Was this interview observed?
[] 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 ________