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[p.47]


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.

U.S. Department of Commerce
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service

U.S. Health Interview Survey

1. Book ____ of ____ Books

2. Street address (House No., Street, Apt. No. or other identification) ________

City ____
State ____
ZIP code _ _ _ _ _

Segment

Sheet No. ____
Line No. ____

3. Year built -- If "Ask" box is "X"d, complete this item before the interview

[] Ask
[] Do not ask
When was this structure originally built?
[] Before 4--1--60 (Continue interview)
[] After 4--1--60 (Go to Q. 13c, complete if required and end interview)

4. Special dwelling place name

Type
Type code
Description of Sample Unit (Room No.,, Bed No., etc.)
Sample Unit Number

5. PSU ____

6a. Segment number

6b. Segment type

A
B
P
LSDP

7. Serial Number

8. Sample

B

9. R.O. Number

10. I.D. Code

11. What is your mailing address? (If different from 2) ____

[] Same as 2
City ____
State ____
Zip Code ____

12. Type of living quarters (Mark appropriate box with an "X")

1 [] Housing unit
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?

[] Yes (fill Table X)
[] No

[] b. Are there any occupied or vacant living quarters besides your own on this floor?

[] Yes (fill Table X)
[] No

[] c. 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 (14 and 15)
[] All other (16)


14. Do you own or rent this place?
[] Own (15a)
[] Rent (15b)
[] Rent free (15a)


15 a. (Own or rent free) Does this place have 10 or more acres?
[] Yes (15c)
[] No (15d)


b. (Rent) Does the place you rent have 10 or more acres?
2 [] Yes (15c)
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?
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. What is the telephone number here?

Telephone number ___________
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)

Number of M.V. Accident Supplements Required ___
[] None (Enter ending time in item 21.)

18. Was the interview observed?

1[]Yes
2[] No
Name of observer_______

19. Interviewer's name ________

Code ____

20. Noninterview reason
Type A

1 [] Refusal (Describe in a footnote)
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
Type B
1 [] Vacant -- nonseasonal
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____

Type C

1 [] Demolished
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

Entire Household
Date ____
Beginning Date ____
Ending time ____
Record of return calls for individual respondents
Person No. _____
Date ____
Beginning time ____
Ending time ____

WASH. USE ONLY

Comp Int.
1[] Yes
2[] No


Calls

Date of completion

Length

Time of day