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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

AREA
B
P
LSP

3. Serial number ____

4. Sample

B__

5. D.C.C. number ____

6. I.D. code ____

7. Book ____ of ____ Books

8. Street address (House No., Street, Apt. No. or other identification) ________

City ____
State ____
ZIP code _ _ _ _ _

Listing Sheet

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 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 (Q. 1)


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


15a. 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 (Q. 1)
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?
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 ____

[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

[1-7/Com. omitted here - only one example listed]


Date ____
Beginning time ____
Ending time ____

[p. 72]

E

If this questionnaire is for an "EXTRA" unit in a B or NTA segment, enter

Serial No. of original Sample Unit ____
Item No. by which found ____

If NTA segment, also enter FIRST unit listed on property

LISTING SHEET
Sheet number ____
Line number ____
TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS

[Questions 1-11]


[There are 3 identical lines in the survey. Lines 2 and 3 have been omitted here.]

1. Line No. ____

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:

B Segment, go to column 4
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)

[] Y
[] N

5. Are these (specify location) quarters for more than one group of people?

(If "Yes" fill one line for each group)

[] Y
[] N

USE OR CHARACTERISTICS

Occupied

6. Do the occupants of these (specify location) quarters live and eat with any other group of people?

[] Y
[] N

All Quarters

Do these quarters in (specify location) have:

7. Direct access from the outside or through a common hall? (7)

[] Y
[] N

8. A kitchen or cooking equipment for exclusive use?

[] Y
[] 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.)

[] N
[] 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.