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[p.49]


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

Questions on health insurance (Questions 31-33) were asked first and fourth quarters. Questions on X-ray visits (Questions 39-44, Table 12) were asked during second and third quarters. The remaining questions were asked for all four quarters of 1970.

1. PSU ____

2a. Segment number ____

2b. Segment type

[] NTA
[] TA
[] 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 List

Sheet No. ____
Line No. ____

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

[] 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
[] Do not ask

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?

[] Y (fill Table X)
[] N

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

[] Y (fill Table X)
[] N

[] c. Is there any other building on this property for people to live in -- either occupied or vacant?

[] Y (fill Table X)
[] N

[] d. None (item L)


ITEM L

2 [] Rural (14)
1 [] 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?
1 [] Y (15c)
2 [] N (15d)


b. (Rent) Does the place you rent have 10 or more acres?
1 [] Y (15c)
2 [] N (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 [] Y (16)
4 [] N (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 [] Y
5 [] N



16. What type of heating system do you have? (Mark one type only)

01 [] Steam or hot water system
02 [] Central warm air furnace with ducts to individual rooms, or central heat pump
03 [] Build-in electric units (permanently installed in wall, ceiling, or baseboard)
04 [] Floor, wall, or pipeless furnace
05 [] Circulating, radiant, or room heaters, WITH flue or vent, burning gas, oil, or kerosene
06 [] Circulating, radiant, or room heaters (not portable), WITOUT flue or vent, burning gas, oil, or kerosene
07 [] Fireplaces or stoves burning coal, wood, or coke
08 [] Portable room heaters of any kind
09 [] Other (Describe) ____
10 [] None, unit is not heated



17. Do you have air conditioning?

1 [] Y -- individual room unit
2 [] Y -- Central air conditioning
3 [] N




18. What is the telephone number here? _ _ _ _ _ _ _ _ _ _

2 [] None


19. Was this interview observed?

1 [] Y
2 [] N

20. Interviewer's name ____

Code ____



21. 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) ____




22. Record of calls at household

Entire Household

[1-6]/Com. ____
Date ____
Beginning Date ____
Ending time _____




ITEM N

[] X-rays
[] Release
[] No release


[] No X-rays