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Appendix III. Questionnaire
The items below show the exact contact and wording of the basic questionnaire used in the nationwide household survey of the U.S. National Health Interview 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.
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
U.S. Health Interview Survey
2. Street address (House No., Street, Apt. No. or other identification) ________
State ____
ZIP code _ _ _ _ _
Segment
Line No. ____
3. Year built -- If "Ask" box is "X"d, complete this item before the interview
[] Do not ask
[] After 4--1--60 (Go to Q. 13c, complete if required and end interview)
4. Special dwelling place name
6b. Segment type
B
P
LSDP
11. What is your mailing address? (If different from 2) ____
City ____
State ____
Zip Code ____
12. Type of living quarters (Mark appropriate box with an "X")
2 [] Other Unit
13. Ask:
[]a. []b. []c. []None (Item L)
[] a. Are there any occupied or vacant living quarters besides your own in this building?
[] No
[] b. Are there any occupied or vacant living quarters besides your own on this floor?
[] No
[] c. Is there any other building on this property for people to live in -- either occupied or vacant?
[] No
ITEM L
[] All other (16)
14. Do you own or rent this place?
[] Rent (15b)
[] Rent free (15a)
15 a. (Own or rent free) Does this place have 10 or more acres?
[] No (15d)
b. (Rent) Does the place you rent have 10 or more acres?
4 [] No (15d)
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. What is the telephone number here?
2 [] None
17. MOTOR VEHICLE ACCIDENT CHECK ITEM
Review question 30 to determine how many motor vehicle supplements need to be completed. (Fill a separate supplement for each different accident reported)
[] None (Enter ending time in item 21.)
18. Was the interview observed?
2[] No
19. Interviewer's name ________
20. Noninterview reason
Type A
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____
Type C
2 [] In sample by mistake
3 [] Eliminated in sub--sample
4 [] Built after April 1, 1960
5 [] Other (Specify) ____
21. Record of calls at household
Beginning Date ____
Ending time ____
Date ____
Beginning time ____
Ending time ____
WASH. USE ONLY
2[] No
Calls
Date of completion
Length
Time of day