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[p. 48]

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

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

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

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

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

* Apply household membership rules.

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?

2. How is -- related to -- (Head of Household)?

3. How old was -- on his last birthday? (Enter Age and circle Race and Sex) ____

C
I. Record the number of Hospitalizations, and Doctor Visits.

II. Record each condition in the person's column, with the question number(s) where it was reported.

If 17 years old or over, ask:
4. Is -- now married, widowed, divorced, separated, or never married? Mark one box for each person

H
If related persons 19 years old or over are listed in addition to the respondent, say:
We would like to have all adults who are at home take part in the interview.
Is your --, your --, etc., at home now?

If other eligible respondents are at home, ask:
Would you please ask --, --, etc., to join us?

(This survey is being conducted to collect information on the Nation's health. I will ask about visits to doctors and dentists, illness in the family, and other health related items.) (HAND CALENDAR)

The first few questions refer to the past 2 weeks, that is, the 2 weeks in red on that calendar, beginning Monday, ____, and ending this past Sunday, ____.

5a. During those 2 weeks, did -- stay in bed because of any illness or injury?

[] Yes (5b)
[] No (If age: 17+ (5c), 6-16 (5d), Under 6 (5f))

b. During that 2-week period, how many days did -- stay in bed all or most of the day?

Days ____ (If age: 17+ (5c), 6-16 (5d), Under 6 (5f))

c. During those 2 weeks, how many days did illness or injury keep -- from work? (For females): not counting work around the house.

d. During those two weeks, how many days did illness or injury keep -- from school?


If BOTH bed days AND work or school days, ask:
e. On how many of these -- days lost from [work/school] did -- stay in bed all or most of the day?

f. (NOT COUNTING the day(s)
[in bed
lost from work
lost from school] )
Were there any (other) days during the past 2 weeks that -- had to cut down on the things he usually does because of his health?

g. (Again, NOT COUNTING the day(s)
[in bed
lost from work
lost from school])
How many days did he cut down for as much as a day?

If 1+ days in Q. 5, ask 6; otherwise go to next person.
6 a. What condition caused -- to
[stay in bed
miss work
miss school
cut down]
during the past 2 weeks?

b. Did any other condition cause him to
[stay in bed
miss work
miss school
cut down]
during that period?

c. What condition? ____

[p. 49]

7a. During the past 2 weeks, did anyone in the family go to a dentist?

b. Who was this? Mark "Dental visit," box in person's column.

c. During the past 2 weeks, did anyone else in the family go to a dentist?

For each person with "Dental visit," ask:
d. During the past 2 weeks, how many times did -- visit a dentist?

If "Dental visit," ask:
8a. For what (other) condition did -- see the dentist? Enter condition in 8a.

b. Did -- see the dentist for any other specific condition?

For each condition in 8a, ask:
c. During the past 2 weeks was -- sick because of his --?

9a. Has anyone in the family been a patient in a hospital during the past 2 weeks?

b. Who was this? - Mark "In hospital" box in person's column.

c. During the past 2 weeks, was anyone else a patient in a hospital?

If "In hospital," ask:
10a. For what condition was -- in the hospital?

b. While -- was in the hospital did he talk to a doctor about any other condition?

c. What condition?

11. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? (Do not count the doctors he saw while in the hospital.)

(Beside those visits)
12a. During that 2-week period did anyone in the family go to a doctor's office or clinic for shots, X-rays, tests, or examinations?


b. Who was this? -Mark "Doctor visit" box in person's column.


c. Anyone else?


If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?


13a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?


b. Who was the phone call about? -Mark "Phone call" box in person's column.


c. Any calls about anyone else?


If "Phone call," ask
d. How many telephone calls were made to get medical advice about --?


Make entry from Q.'s 11-13 in DV box for all persons.
Ask Q. 14a for each person with visits in DV box.

14a. For what condition did -- see or talk to a doctor during the past 2 weeks?


b. Did -- see or talk to a doctor about any specific condition?


c. What condition?


d. During that period, did -- see or talk to a doctor about any other condition?


e. During the past 2 weeks was -- sick because of her pregnancy?


f. What was the matter? -Anything else?


INTERVIEWER CHECK ITEM
Check one box OR ask Q.15


[p. 50]

15. ABOUT how long has it been since -- saw or talked to a medical doctor?
(Estimate is acceptable. If less than 1 year, check appropriate "Months" box; if more than 1 year, enter number of whole years).

Now I'm going to read a list of conditions;
16a. During the past 12 months, has anyone in your family (you, your --, etc) had any of the following conditions - If "Yes," ask b and c

Ages 17+
17a. 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?

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


If 45+ years and not "working," "keeping house," or "going to school, ask:
c. Is -- retired?

Ages 6-16

18a. 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

19a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

Ages Under 1 yr.

20a. Is -- limited in any way because of his health?

b. In what way is he limited? ________ (25)

21a. Does -- health keep him from working?

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

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

22a. In terms of health, is -- presently able to (work - keep house) at all?

b. Is he limited in the kind of (work - housework) he can do because of his health?

c. Is he limited in the amount of (work - housework) he can do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

23. In terms of health would -- be able to go to school?

24a. Does (would) -- have to go to a certain type of school because of his health?

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

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

25a. What condition causes this limitation?
If "old age," ask:
Is this limitation caused by any specific condition?

b. Is this limitation caused by any other conditions?

c. What conditions?

If 2+ conditions reported in 25, ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?

[p. 51]

26a. Has -- been in a hospital at any time since ____ a year ago?

b. How many times was -- in a hospital since _____ a year ago?

27a. Was anyone in the family in a nursing home, convalescent home or similar place since ____ a year ago?

b. Who was this? - Mark "Yes" in person column.

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

For each child 1 year old or under, ask:
28a. When was -- born?
If on or after the date stamped on 26, ask 28b.

b. Was -- born in a hospital?
If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 29 and item C.
If "Yes" and a hospitalization is entered for the mother and/or baby, ask 31c for each.

c. Is this hospitalization included in the number you gave me for --?
If "No," correct entries in Q. 26 and item C for mother and/or baby.

29. Not applicable - Use for footnotes

These next questions are about motor vehicle accidents, that is, accidents involving cars, trucks, buses, motorcycles and so forth. We are interested in all types of motor vehicle accidents even if no one was injured.
30a. During the past 12 months, has -- been in a motor vehicle accident either as a (driver), passenger or pedestrian?

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

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

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

For all persons age 14 years of age and older, ask:
31a. Has -- driven a motor vehicle during the past 12 months?

R
For persons 19 years old or over, show who responded for (or was present during the asking of) Q.5-31. If the person 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.

[p. 56]
IF 65 OR OVER, ASK:
33. (These next questions are about Social Security Medicare.) Does -- have a Medicare card?
[] Yes (NP)
[] No (NP)

If "Yes" for one or more persons in Q.33, ask:
34. It would be helpful if I could see --, --, Medicare card(s) to determine the coverage. May I please see this (these) card(s)?
(Transcribe the information from the card or check the appropriate "No card" box.)

For each person with BOTH "Hospital" and "Medical" boxes BLANK in Q.34, ask:
35a. Is -- covered by that part of Social Security Medicare which pays for hospital bills?

b. Is -- covered by that part of Medicare which pays for doctor's bills, that is, the Medicare plan for which he or some agency must pay $4.00 a month?

I
For each person, check Q's 32 through 35 and determine if "Covered" by either insurance or Medicare or "Not covered/"

36. (Many people do not carry health insurance for various reasons). Would you mind telling me why -- does not have health insurance?

If 17 years old or over, ask:
37a. What is the highest grad -- attended in school?

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

Ask for all males 17 years or over:
38a. Did -- ever serve in the Armed Forces of the United States?

b. Was any of his service during a war?


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


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

Ask for all persons 17 years old or over:
39a. Did -- work at any time last week or the week before - (For females): not counting work around the house?

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

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

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

If "Yes" in 39c only, questions 40a through 40d apply to this person's LAST full-time civilian job.

Ask for all persons with a "Yes" in 39a, b, or c.
40a. Who does (did) -- work for?

b. What kind of business or industry is this?

c. What kind of work is (was) -- doing?

Fill 40d from entries 40a-40c, if not clear, ask:
d. Class of worker

INTERVIEWER CHECK ITEM
If under 17 years, or not in Labor Force (Q.40a-d blank)
If in Labor Force (Q.40 filled) refer to WL in item C and make appropriate entry.

Earlier you said that -- lost days -- days from work during the past 2 weeks -
(If self-employed , ask c; for other workers, ask a)
41a. On how many of these -- days that he lost from work was he paid any wages by his employer?

b. On how many of these -- days was he paid for his full day's pay?

c. (In addition to this sick leave pay) Will -- be paid for some of the income he lost on these days, through some (other) source, such as loss of pay insurance, workman's compensation or State temporary disability insurance?

d. Who will pay this? (Enter verbatim response)

e. How much income did he lose because of the -- days lost from work?

f. Is this before or after taxes?

g. How much does -- usually earn per week?
If not regularly employed, ask: How much would -- have earned in a week if he wasn't sick?

h. Is this before or after taxes?

42. Which of these income groups represents your total combined family income for the past 12 months -- that is yours, your --'s (Show Card I) Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rent from property and so forth.

*For each family with A through E checked in question 42, ask:
43a. During the past 12 months, has anyone in the family (you, your --, etc.) received any public assistance, relief, or welfare money from the State or local governments?

b. At present, are you or any member of your family receiving any of this aid?

43c. Which family members receive this aid? Anyone else? ____

If "Receives aid," ask:
d. What kind of aid does -- receive?