[p.49]
Appendix III. Questionnaire and Flash Cards
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.
[] TA
[] B
[] P
[] LSDP
8. Street address (House No., Street, Apt. No. or other identification)____
State ____
ZIP code _ _ _ _ _
Segment List
Line No. ____
9. Year built - If "Ask" box is "X"d, complete this item before the interview
[] 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? ____
State ____
ZIP code _ _ _ _ _
[] Same as 8
11. Special dwelling place name ____
Description of sample unit (Room No., Bed No., etc.) ____
Sample unit number ____
Type code ____
12. Type of living quarters
2 [] Other Unit
13. Ask:
[] a. Are there any occupied or vacant living quarters besides your own in this building?
[] N
[] b. Are there any occupied or vacant living quarters besides your own on this floor?
[] N
[] c. Is there any other building on this property for people to live in -- either occupied or vacant?
[] N
[] d. None (item L)
ITEM L
1 [] 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?
2 [] N (15d)
b. (Rent) Does the place you rent have 10 or more acres?
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?
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?
5 [] N
16. What type of heating system do you have? (Mark one type only)
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?
2 [] Y -- Central air conditioning
3 [] N
18. What is the telephone number here? _ _ _ _ _ _ _ _ _ _
19. Was this interview observed?
2 [] N
21. Noninterview reason
Type A
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
Type B
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____
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
Date ____
Beginning Date ____
Ending time _____