[p.60]
APPENDIX V. QUESTIONNAIRE: PERSON 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
2. Street address- house no, street, apt. No. or other ident.
City ________
State ________
ZIP code ________
For area segments enter:
Line No. ________
3. [] Ask [] Do not ask
(If marked "ask" do so before the interview)
When was this structure originally built?
[] After 4-1-60 -go to Q13c, ask if required and end interview
Sample No. ________
Type ________
[] B
[] P
[] LSDP
10. I.D code ________
SDP type code ________
Complete items 11-21 and 23 at the end of the interview
11. Mailing address-if different from 2
City ________
State ________
ZIP code ________
[] Same as 2
12. Type of living quarters- mark appropriate box with an "X"
1[] Other unit
13. [] Do not ask Q 13- 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 16
14. Do you own or rent this place?
[] Rent- Ask 15b
[] Rent free-Ask 15a
15a. (own or rent free) does this place have 10 or more acres?
[] No-ask d
b. (rent) does the place you rent have 10 or more acres?
[] No-ask d
c. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $50 or more?
4[] No
d. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $250 or more?
5[] No
16. How many rooms are in this -- (unit)? Count the kitchen but not the bathroom
17. How many bedrooms are in this--(unit)? If "None" describe in footnotes.
18. What is the telephone number here?
2[] None
19. Motor vehicle accident check box:
Review question 27c to determine how many motor vehicle supplements need to be completed. (fill a separate supplement for each different accident reported)
[] None
20. Was this interview observed?
[] No
21. Interviewer's name ________
Code ________
22. Noninterview reason
Type A
1[] No one at home-repeated calls
2[] Temporarily absent
3[] Other-specify ________
1[] Vacant -seasonal
2[] Usual residence elsewhere
3[] Armed Forces
4[] Other -specify ________
1[] In sample by mistake
2[] Eliminated in sub-sample
3[] Built after April 1 1960
4[] Other -specify ________
23. Record of calls at household
Item 1
Beginning time ________
Ending time ________
Date ________
Beginning time ________
Ending time ________
Beginning time ________
Ending time ________
Date ________
Beginning time ________
Ending time ________
Beginning time ________
Ending time ________
Date ________
Beginning time ________
Ending time ________
Beginning time ________
Ending time ________
Date ________
Beginning time ________
Ending time ________
Beginning time ________
Ending time ________
Date ________
Beginning time ________
Ending time ________