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[p.47]


Appendix III. Questionnaire and Flash Cards

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. PSU ____

2a. Segment number ____

2b. Segment type

A
B
P
LSDP

3. Serial number ____

4. Sample

B_

5. R.O. number ____

6. I.D. code ____

7. Book ____ of ____ Books

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

City ____
State ____
ZIP code _ _ _ _ _

Segment

Sheet No. ____
Line No. ____

9. 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)

10. What is your mailing address? ____

City ____
State ____
Zip Code _ _ _ _ _
[] Same as 8

11. Special dwelling place name ____

Type ____
Description of sample unit (Room No., Bed No., etc.) ________
Sample unit number
Type code


12. Type of living quarters

1 [] Housing unit
2 [] Other Unit

13. Ask:

[] 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

[] d. None (item L)


ITEM L

[] Rural (14)
[] 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 (16)
4 [] No (16)


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 (16)
4 [] No (16)


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? _ _ _ _ _ _ _ _ _ _

2 [] None

17. Was this interview observed?

1 [] Yes
2 [] No

18. Interviewer's name ________

Code ____


19. 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) ____



20. Record of calls at household

Entire Household

Item 1--6/Com.
Date ____
Beginning Date ____
Ending time ____

Record of return calls for individual respondents
Item 1-6/Com.
Person No. _____
Date ____
Beginning time ____
Ending time ____