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[p.57]


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 ____

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 __
[] 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 and ZIP code? ____

[] Same as 8
City ____
State ____
ZIP code ____

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 (Q1)


14. Do you own or rent this place?
[] Own
[] Rent
[] Rent free


15 a. How many acres of land are included?
1 [] 10 or more acres (b)
2 [] Less than 10 acres (c)


b. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $50 or more?
[] 2 Y (Q1)
[] 4 N (Q1)


c. 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 is the telephone number here? _ _ _ _ _ _ _ _ _ _

2 [] None

17. Was this interview observed?

[] 1 Y
[] 2 N

18. Interviewer's name ____

Code ____

ITEM N

Number of Hearing Supplements required _____

[p. 58]


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
[1-7/Com.]
Date ____
Beginning time ____
Ending time