[p.57]
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
2b. Segment type ____
TA ____
B ____
P ____
LSDP ____
8. Street address (House No., Street, Apt. No. or other identification) ________
State ____
ZIP code ____
Line No. ____
9. Year built - If "Ask" box is "X"d, complete this item before the interview
[] Do not ask
When was this structure originally built?
[] After 4-1-60 Go to Q. 13c, complete if required and end interview
10. What is your mailing address and ZIP code? ____
City ____
State ____
ZIP code ____
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
[] N
[] N
[] N
ITEM L
1 [] All other (Q1)
14. Do you own or rent this place?
[] Rent
[] Rent free
15 a. How many acres of land are included?
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?
[] 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?
[] 5 N
16. What is the telephone number here? _ _ _ _ _ _ _ _ _ _
17. Was this interview observed?
[] 2 N
ITEM N
Number of Hearing Supplements required _____
[p. 58]
19. Noninterview reason
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
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) ____
20. Record of calls at household
[1-7/Com.]
Beginning time ____
Ending time