[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
1. PSU ____
2b. Segment type
B
P
LSP
8. Street address (House No., Street, Apt. No. or other identification) ________
State ____
ZIP code _ _ _ _ _
Listing Sheet
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 _ _ _ _ _
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 (Q. 1)
14. Do you own or rent this place?
[] Rent
[] Rent free
15a. 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 (Q. 1)
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
[p. 58]
19. Noninterview reason
Type A
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
[1-7/Com. omitted here - only one example listed]
Beginning time ____
Ending time ____
[p. 72]
E
If this questionnaire is for an "EXTRA" unit in a B or NTA segment, enter
Item No. by which found ____
If NTA segment, also enter FIRST unit listed on property
Line number ____
[Questions 1-11]
[There are 3 identical lines in the survey. Lines 2 and 3 have been omitted here.]
LOCATION OF UNIT
2. Where are these quarters located? (Enter exact description or location, e.g., basement, 2nd floor, rear)
If outside Area Segment boundary, specify in notes, STOP Table X and continue with item 13 or L1
3. If listed, enter sheet and line number and stop.
If unlisted and:
Area Segment, go to column 5.
L ____
B SEGMENTS ONLY
4. INTERVIEWER: Are these quarters within the specific sample address shown in columns 2-4 of the B Segment list?
(If "Yes," continue Table X. If "No," STOP Table X and continue with item 13 or L)
[] N
5. Are these (specify location) quarters for more than one group of people?
(If "Yes" fill one line for each group)
[] N
USE OR CHARACTERISTICS
Occupied
6. Do the occupants of these (specify location) quarters live and eat with any other group of people?
[] N
All Quarters
Do these quarters in (specify location) have:
7. Direct access from the outside or through a common hall? (7)
[] N
8. A kitchen or cooking equipment for exclusive use?
[] N
CLASSIFICATION
9.
N - Not a separate unit, add occupants to this questionnaire (Complete a separate questionnaire for each unrelated person or family group.)
HU -- Separate unit (Interview on a separate questionnaire.)
Ot -- Separate unit (Interview on a separate questionnaire.)
[] HU
[] Ot
IF HU IN B SEGMENT ASK:
10. In what year were these quarters (specify location) created? (If 1959 or 1960, specify "F" if first half, or "L" if last half) ____
11. (If before July 1960)
What was the name of the household had of these quarters on April 1, 1960? ____
NOTE: Be sure to continue interview with item 13 or L of the Household Page.