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p_personapproach

[p.61]


PERSON

Person approach

a. What is the name of the head of this household? Enter name in first column.

First name ________
Last name ________

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

First name ________
Last name ________

c. I have listed (Read names). Is there anyone else staying here now, such as friends, relatives, or roomers?

[] Yes (apply household membership rules)
[] No

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

[] Yes (apply household membership rules)
[] No

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

[] Yes (apply household membership rules)
[] No

If any adult males listed, ask:
f. Are any of the persons in this household now on full-time active duty with the armed forces of the United States?

[] Yes (delete)
[] No

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

Relationship ________
Head ________

3. How old was --on his last birthday?
Also mark Race and sex

Age ____
Race
0[] W
1[] N
2[] OT
Sex
0[] M
1[] F

C
Record all conditions for a person in this space in the person's column with question number(s) where reported.
Also enter the number of Hospitalizations and Doctor visits.
Check the home care box, and the No cut down Days box, if applicable.

H ________
DV________
HC ________
[] No cut Down days
Q. No ____
Condition ____

If 17 years old or over, ask:
4. Is -- now married, widowed, divorced, separated, or never married? Mark one box for each person.
If person under 17 is or has been married mark the "Und 17" box and give marital status in a footnote.

0[] Under 19 years
1[] At home
2[] Not at home

Hand calendar to respondent.
5a. During the past two weeks (the 2 weeks outlined in red on the calendar) did --stay in bed all or most of the day because of any illness or injury?

[] Yes -ask b
00[] No- ask c

b. During the two weeks period, how many days did -- have to stay in bed all or most of the day?

Days ______ (ask c)

c. During that two weeks period, did he have to cut down on the things he usually does because of illness or injury?

[] Yes (ask d)
[] No (go to 6a)

d. Did -- have to cut down for as much as a day?

[]Yes (Ask c)
00[] No -go to 6a

e. How many days in total did -- have to cut down during that two week period?

Days ____ (ask 1 or 6)
If under 6 yrs, go to 6a.

If 17 years old or over ask:
f. How many days did illness or injury keep -- from work during these two weeks?
For females add- not counting work around the house.

00[] None
Days ____ (go to 6a)

If 6-16 years old ask:
g. How many days did illness or injury keep -- from school during those two weeks?

00[] None
Days ____ (go to 6a)

)

If 1+days recorded in Q5e,ask:
6a. What condition caused--to cut down on the things he usually does during the past two weeks?
Enter condition in C above.

[] No cut down days (go to next person)

b. During the past two weeks, did any other conditions cause him to cut down on the things he usually does?

[] Yes (reask a and b)
[] No (go to next person)

7. During the past 2 weeks (the 2 weeks outlined in red on that calender) how many times has -- seen a doctor either at home or at a doctor's office, or clinic?

[] None
Number of visits ____

8a. (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 (ask b and c)
[] No (go to 9)

b. Who was this? ________
Mark "Yes" in person's column

[] Yes
Doctor's visits ________

Anyone else?

[] Yes - reask b and c
[] No - go to d

For each "Yes" marked, ask:
d. How many times did -- visit the doctor during that period?
Exclude visits made on "mass " basis

Number of visits ________

9a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Yes -ask b and c
[] No - go to 10

b. If "Yes" ask: who was the phone call about? ________
Mark Yes in person's column.

[] Yes

c. Any calls about anyone else?

[] Yes -reask b and c
[] No-go to d

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

Number of calls ________

[] No 2 week visits (ask 11)
If doctor was seen or talked to during the past two weeks, ask:
10a. For what condition did -- see or talk to a doctor during the past two weeks?

Enter condition here and in c above. ________

b. During that period, did -- see or talk to a doctor for any other condition?
If pregnancy reported ask: During the past 2 weeks was -- sick because of her pregnancy?
If "Yes" ask: what was the matter?

[] Yes -reask 10a
[] No- go to next person

XV[] 2 week visits in Q 7-9
If no visits reported in questions 7-9, ask:
11. About how long has it been since -- saw or talked to a doctor? (estimate is acceptable. If less than 1 year, check appropriate "Months" box: if more than 1 year, enter number of whole years)

OX[] Past 2 weeks not reported- Reask Q. 7 and 10
XX[] In hospital in pas 2 weeks. Ask Q.10
VO[] 2 weeks-6 months
XO[] Over 6-12 months
Years ____
00[] Never

[p.62]

Now I'm going to read a list of conditions:

12a. During the past 12 months has anyone in the family (you, your--etc) had any of the following conditions. If "Yes" ask b and c.

1. Gallstones?
[] Yes
[] No
2. Any other gallbladder trouble?
[] Yes
[] No
3. Hemorrhoids or piles?
[] Yes
[] No
4. Cirrhosis of the liver?
[] Yes
[] No
5. Fatty liver?
[] Yes
[] No
6. Hepatitis?
[] Yes
[] No
7. Yellow jaundice?
[] Yes
[] No
8. Any other liver trouble?
[] Yes
[] No
9. A disease of the pancreas?
[] Yes
[] No
10. A disease of the esophagus?
[] Yes
[] No
11.Any other disease that affects swallowing?
[] Yes
[] No
12. Peptic ulcer?
[] Yes
[] No
13. Duodenal ulcer?
[] Yes
[] No
14. Stomach or gastric ulcer?
[] Yes
[] No
15. Any other ulcer?
[] Yes
[] No
16.Hiatal hernia?
[] Yes
[] No
17. Umbilical hernia?
[] Yes
[] No
18. Any other hernia or rupture?
[] Yes
[] No
19. Gastritis?
[] Yes
[] No
20. Frequent indigestion?
[] Yes
[] No
21. Cancer of the stomach?
[] Yes
[] No
22. Any other stomach trouble?
[] Yes
[] No
23. Enteritis?
[] Yes
[] No
24. Diverticulitis?
[] Yes
[] No
25. Colitis?
[] Yes
[] No
26. Constipation
[] Yes
[] No
27. Spastic colon?
[] Yes
[] No
28. Cancer of the colon or rectum?
[] Yes
[] No
29. Any other cancer of the digestive system?
[] Yes
[] No
30. Any other intestinal trouble?
[] Yes
[] No
31. Any other condition of the digestive system?
[]Yes
[] No

b. Who was this? ________

c. During the past 12 months has anyone else had....?

1. Gallstones?
[] Yes
[] No
2. Any other gallbladder trouble?
[] Yes
[] No
3. Hemorrhoids or piles?
[] Yes
[] No
4. Cirrhosis of the liver?
[] Yes
[] No
5. Fatty liver?
[] Yes
[] No
6. Hepatitis?
[] Yes
[] No
7. Yellow jaundice?
[] Yes
[] No
8. Any other liver trouble?
[] Yes
[] No
9. A disease of the pancreas?
[] Yes
[] No
10. A disease of the esophagus?
[] Yes
[] No
11.Any other disease that affects swallowing?
[] Yes
[] No
12. Peptic ulcer?
[] Yes
[] No
13. Duodenal ulcer?
[] Yes
[] No
14. Stomach or gastric ulcer?
[] Yes
[] No
15. Any other ulcer?
[] Yes
[] No
16.Hiatal hernia?
[] Yes
[] No
17. Umbilical hernia?
[] Yes
[] No
18. Any other hernia or rupture?
[] Yes
[] No
19. Gastritis?
[] Yes
[] No
20. Frequent indigestion?
[] Yes
[] No
21. Cancer of the stomach?
[] Yes
[] No
22. Any other stomach trouble?
[] Yes
[] No
23. Enteritis?
[] Yes
[] No
24. Diverticulitis?
[] Yes
[] No
25. Colitis?
[] Yes
[] No
26. Constipation
[] Yes
[] No
27. Spastic colon?
[] Yes
[] No
28. Cancer of the colon or rectum?
[] Yes
[] No
29. Any other cancer of the digestive system?
[] Yes
[] No
30. Any other intestinal trouble?
[] Yes
[] No
31. Any other condition of the digestive system?
[]Yes
[] No

Ask 17+:
13a. 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?

1[] Working (18)
2[] Keeping house (18)
3[] Retire (17)
4[] Going to school (20)
5[] 17+ something else (17)
6[] 6-16 something else (19)

If "something else" and 45+ years of age, ask:
b. Is --retired?

[] Yes
[] No

If "something else" and under 45 years of age, or no in Q 13b, ask:
c. What was --doing? ________

Ages 6-16
14a. What was -- doing most of the past 12 months -going to school or doing something else?________

If "something else" ask:
b. What was -- doing? _______

Ages 1-5:
15a. In terms of health, is -- able to take part at all in ordinary play with other children?

[] Yes (15b)
1[] No (21)

b. Is he limited in the kind or amount of play because of his health?

2[] Yes (21)
4[] No (go to next person)

Ages under 1yr.
16a. Is-- limited in any way because of his health?

1[] Yes (16b)
4[] No - go to next person

b. In what way is he limited? Specify ________ (go to 21)

[p.63]

17a. In terms of health, is -- able to work?

[] Yes (17b)
1[] No (21)

b. Is -- limited in the kind or amount of work he could do because of his health?

2[] Yes (21)
[] No (18c)

18a. Is --limited in the kind or amount of (work, housework) he can do because of his health?

[] Yes (18b)
[] No (18c)

b. Is -- able to (work, keep house) at all?

2[] Yes (21)
1[] No (21)

c. Is -- limited in the kind or amount of other activities because of his health?

3[] Yes (21)
4[] No- go to next person

19. In terms of health, is -- able to go to school?

[] Yes (20)
1[] No (21)

20a. Does (would) he have to go to a certain type of school because of his health?

2[] Yes (21)
[] No (20b)

b. Is he (would he be) limited in school attendance because of his health?

2[] Yes (21)
[] No (20c)

c. Is -- limited in the kind or amount of other activities because of his health?

3[] Yes (21)
4[] No- go to next person

21a. What condition causes this limitation? ________

b. Is this limitation caused by any other conditions?

[]Yes (21c)
[] No- go to next person

c. What conditions? Any other conditions?

[] Yes
[] No

22a. Has -- been in a hospital at any time since -- a year ago?

[] Yes- ask b
[] No- go to next person

b. How many times was -- in a hospital during that period?

Times ________

Examine ages of all persons listed. For each child 1 year old or under, ask:
23a. When was -- born? If on or after the date stamped in 22a, ask 23b

Month ____
Day ____
Year ____

b .Was -- born in a hospital?
If "Yes" and no hospitalizations entered in his column enter "1" in 22. If "Yes" and a hospitalization is reported for the mother and baby ask 23c.

[] Yes
[] No

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

[] Yes
[] No

24a. Has anyone in the family been in a nursing home, convalescent home or similar place since-- a year ago?

[] Yes -ask 24b
[] No-go to 25

b. Who was this? ________
Mark "Yes" in person's column.

[] Yes

For each "Yes" marked ask:
c. During that period, how many times was -- in a nursing home or similar place?

Times ________

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

0[] Under 55-stop
[] 55 or over-ask a

25a. Does -- need any help in bathing, dressing or putting on his shoes?

1[] Yes-stop
[] No

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

2[] Yes-stop
[] No

c. Does -- need anyone's help when walking upstairs or getting from room or room?

3[] Yes-stop
[] No

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

4[] Yes -stop
5[] No

26a. During the past 12 months, has -- received any care at home from a nurse?

[] Yes (ask b and c)
[] No -stop

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

Times ________

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

1[] Yes
2[] No

These next questions are about motor vehicles accidents, that is, accidents, involving cars, trucks, buses, motorcycles, and so forth. We are interested in all types of motor vehicles accidents even if no one was injured.
27a. During the past 12 months, has -- been in a motor vehicle accident either as a (driver), passenger or pedestrian?

[] Yes -ask b
[] No- go to next person

b. How many motor vehicle accidents has -- been in during the past 12 months?

Number of accidents ________

c. On what date(s) did the accident(s) happen?

Month ________
Day ________
Year ________

d. Was -- in any other motor vehicle accident during the past 12 months?

[] Yes -reask c and d
[] No- go to next person

[p.71]

Ask for all persons 14 years of age and older:
28a. Has -- driven a motor vehicle during the past 12 months?

XV[] Under 14 years -go to next person
XX[] No
[] Yes-ask 28b

b. How many years has -- been driving?

00[] Less than 1 year
________ Number of years

R
(Q5-28)
For persons 19 years old or over, show who responded for (or was present during the asking of Q5-28. 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.

0[] Responded for self-entirely
1[] Responded for self-partly
Person ____ was respondent

These next questions are about health insurance. We are interested in all kinds of health insurance which pays for most kinds of all illness. However, we do not want to include insurance which pays only for accidents.
29a. Is anyone in the family covered by a health insurance plan which pays all or part of a hospital bill?

[] Yes -ask b and c
[] No- go to 30a.

b. What is the name of the plan?
Record in table H-1 ________

c. Is anyone in the family covered by any other health insurance plan which pays all or part of a hospital bill?

[] Yes- reask b and c
[] No-complete Table H-1 for each plan reported

30a. (Besides the -- plan you told me about) is anyone in the family covered by a health insurance plan which pays all or part of a surgeon's bill?

[] Yes- ask b and c
[] No- go to 31a

b. What is the name of the plan?
Record in table H-1 ________

c. Is anyone in the family covered by any other health insurance plan which pays all or part of a surgeon's bill?

[] Yes -reask b and c
[] No-complete Table H-1 for each plan reported

31a. (Besides the --plan you told me about) is anyone in the family covered by a health insurance plan which pays all or part of a doctor's bill for home calls or office visits?

[] Yes-ask b and c
[] No- go to 32a

b. What is the name of the plan? ________

c. Is anyone in the family covered by any other health insurance which pays all or part of a doctor's bill for home calls or office visits?

[] Yes- reask b and c
[] No-complete Table H-1 for each plan reported

32a. (Besides the --plan you told me about) is anyone in the family covered by a deductible health insurance plan which pays some part of a bill for doctor visits or for hospital or surgical care, after a certain amount has been paid by the family?

[] Yes - ask b and c
[] No- go to 33a

b. What is the name of the plan? ________

c. Is anyone in the family covered by any other deductible health insurance plan which pays some part of a bill for doctor visits or for hospital or surgical care after a certain amount has been paid by the family?

[] Yes -reask b and c
[] No-complete table H-1 for each plan reported

Interviewer check item:
Mark one box for each person

[option for upto 6 persons; asking the same questions as part of 33 and table H-1]

[] Und. 65- go to next person
[] 65 or over-ask 33a

33a. Is -- covered by that part of social security medicare which pays for doctor visits; that is the medicare plan for which he or some agency must pay 3.00 a month?

[] Yes -ask b
[] No- go to next person

If person is covered by any insurance plan in table H.1 ask for each plan:
b. Is this the (name of plan) you told me about before?

Line no ____
[] Yes
[] No
Go to next person

Wash. use only
H

Type of plan ____
Number of plans ____
Coverage of head ____
S
Type of plan ____
Number of plans ____
Coverage of head ____
D
Type of plan ____
Number of plans ____
Coverage of head ____

[p.72]

TABLE H.1

[option for upto 8 different insurance entries (A to H); questions asked are the same ]

Line A:

1. Name of plan ________

2. Does this plan pay all or part of a hospital bill?

[] Yes
[] No

3. Does this plan pay all or part of a surgeon's bill?

[] Yes
[] No

4. Does this plan pay all or part of a doctor's bill for home calls or office visits?

[] Yes - go to 6
[] No

5. Does this plan pay any part of a doctor's bill for home calls or office visits after a certain amount has been paid by the family?

[] Yes
[] No

6. Which members of the family are covered by (name of plan)? Circle column numbers.

[] Covered
[] 1
[]2
[]3
[]4
[]5
[]6
[] Not covered:
[] 1
[]2
[]3
[]4
[]5
[]6

7. If 2 or more members of family covered by this plan ask: are all these person's covered by the same policy?

[] Yes
[] No-fill separate line for each policy

8. For each person 65+ covered by this plan ask: Is this (name of plan) which covers -- a social security medicare plan?

Person no: ________
[] Yes
[] No

[p.73]

If 17 years old or over, ask:
34a. What is the highest grade--attended in school?

[] Und 17 yrs (go to next question)
[] None
[] Elem
[]1
[]2
[]3
[]4
[]5
[]6
[]7
[]8
[] High:
[]9
[]10
[]11
[]12
[]College
[]1
[]2
[]3
[]4
[]5+

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

[] Yes
[] No

Ask for all males 17 years old or over:
35a. Did --ever serve in the Armed forces of the United States?

[] Yes-ask b
[] No (go to 36)
[] Female (go to 36)

b. Was any of his services during a war?

[] Yes (stop)
[] No (ask 35c)
[] DK (ask 35c)

c. Was any of his service between June 27 1950 and January 31, 1955?

[] Yes-stop
[] No (ask 35d)
[] DK (35d)

d. Was any of his service after January 31 1955?

[] Yes
[] No
[] DK

Ask for all persons 17 years old or over:
36a. Did -- work at any time last week or the week before? For females add: Not counting work around the house.

1[] Yes- go to 37a
[] No -ask both b and c

b. Even though -- did not work during those 2 weeks, does he have a job or business?

2[] Yes- ask c
4[] No-ask c

c. Was he looking for work or on layoff from a job?

[] Yes -ask d
[] No-omit a

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

1[] Looking
2[] Layoff
3[] Both

If "Yes" in 36c only, questions 37a through 37d apply to this person's Last full-time civilian job.
Ask for all persons with a "Yes" in 36a, 36b or 36c
37a. 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 37d from entries in 37a-37c, if not clear, ask:
d. Class of worker:

0[] Pvt. pd
1[] Gov.Fed
2[] Gov. Oth
3[] Own
4[] Non-pd
5[] Nev. worked

Interviewer check item:
If person is under 17 years, or not in labor force (Q.37 a-d blank) check "Not in labor force"
If in Labor force (q.37 filled) refer to Question 5e and make appropriate entry.

4[] Not in labor force or under 17
0[] No work -loss days in LF (go to next person)
[] Work-loss days ________ (go to 38a)

Earlier you said that --lost-- days from work during the past 2 weeks - (if self-employed ask b; for other workers ask a).
38a. Was -- paid any wages by his employer for the days that he lost?

1[] Yes -ask c
[] No-ask b

b. Does -- have any insurance that pays him for the income he lost on these days?

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

c. Did he receive his full day's pay for all of these -- days he lost?

1[] Yes-ask f
2[] No-ask d and e

d. In total, how much income did --lose because of the --days he lost from work?

$________

e. Is this before or after taxes?

1[] Before
2[] After

f. How much does -- usually earn per week?

$________

g. Is this before or after taxes?

1[] Before
2[] After

h. Did -- receive this income for these days through or sick leave plan, loss of pay insurance or some other way?

1[] Sick leave plan
2[] Loss-of-pay insurance
3[] Other-specify ________

39.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.
Group:

1[] A
2[] B
3[] C
4[] D
5[] E
6[] F
7[] G
8[] H
9[] I
X[] J

CARD I
Which of the following income groups represents your total combined family income for the past 12 months? Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rents from property and so forth.

Under $500...Group A
$500-$999... Group B
$1,000-$1,999...Group C
$2,000-$2,999...Group D
$3,000-$3,999...Group E
$4,000-$4,999...Group F
$5,000-$6,999...Group G
$7,000-$9,999...Group H
$10,000-$14,999...Group I
$15,000 and over...Group J