Data Cart

Your data extract

0 variables
0 samples
View Cart



hh_personapproach

[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.

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

2. Street address- house no, street, apt. No. or other ident.

________
City ________
State ________
ZIP code ________

For area segments enter:

Sheet No. ________
Line No. ________

3. [] Ask [] Do not ask
(If marked "ask" do so before the interview)
When was this structure originally built?

[] Before 4-1-60- continue interview
[] After 4-1-60 -go to Q13c, ask if required and end interview

4. Special dwelling place

Name _______
Sample No. ________
Type ________

Card type - X

5. PSU ________

6a. SEG number ________

6b. SEG type

[] A
[] B
[] P
[] LSDP

7. Serial Number ________

8. Sample ________

9. R.O number ________

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"

0[] Housing unit
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?

[] 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 14 and 15
1[] All other - go to 16

14. Do you own or rent this place?

[] Own -Ask 15a
[] Rent- Ask 15b
[] Rent free-Ask 15a

15a. (own or rent free) does this place have 10 or more acres?

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

b. (rent) does the place you rent have 10 or more acres?

[] Yes -ask c
[] 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?

2[] Yes
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?

3[] Yes
5[] No

16. How many rooms are in this -- (unit)? Count the kitchen but not the bathroom

Total rooms ________

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

Number of bedrooms ________

18. What is the telephone number here?

Telephone number ________
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)

________ Number of M.V accident supplements required (enter ending time in item 23)
[] None

20. Was this interview observed?

[] Yes
[] No
Name of observer ________

21. Interviewer's name ________
Code ________

22. Noninterview reason
Type A

0[] Refusal- describe in footnotes
1[] No one at home-repeated calls
2[] Temporarily absent
3[] Other-specify ________
Type B
0[] Vacant -nonseasonal
1[] Vacant -seasonal
2[] Usual residence elsewhere
3[] Armed Forces
4[] Other -specify ________
Type C
0[] Demolised
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

Entire household
Date ________
Beginning time ________
Ending time ________
Record return calls for individual respondents
Person No. _______
Date ________
Beginning time ________
Ending time ________

Item 2

Entire household
Date ________
Beginning time ________
Ending time ________
Record return calls for individual respondents
Person No. _______
Date ________
Beginning time ________
Ending time ________

Item 3

Entire household
Date ________
Beginning time ________
Ending time ________
Record return calls for individual respondents
Person No. _______
Date ________
Beginning time ________
Ending time ________

Item 4

Entire household
Date ________
Beginning time ________
Ending time ________
Record return calls for individual respondents
Person No. _______
Date ________
Beginning time ________
Ending time ________

Item 5

Entire household
Date ________
Beginning time ________
Ending time ________
Record return calls for individual respondents
Person No. _______
Date ________
Beginning time ________
Ending time ________