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[p. 69]


1. Person number ____

You said that -- was in the hospital (nursing home) during the past year.

2. When did -- enter the hospital (nursing home) (the last time)?

Make sure the YEAR is correct

Month ____
Day ____
Year 19 _ _

3. What is the name and address of this hospital (nursing home)?

Name ____
Street ____
City (or county) ____
State ____

4. How many nights was -- in the hospital (nursing home)?

Nights ____

Complete question 5 from entries in questions 2 and 4; if not clear, ask the questions.

5a. How many of these -- nights were during the past 12 months?

Nights ____

b. How many of these -- nights were during the past 2 weeks?

Nights ____

c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?

[] Y
[] N

6. For what condition did -- enter the hospital (nursing home) -- do you know the medical name? If medical name unknown, enter an adequate description. ________

For delivery, ask: Was this a normal delivery?
For newborn, ask: Was the baby normal at birth?
If "No," ask: What was the matter?

Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.

[] Normal delivery
[] Normal at birth
Condition ____
Cause ____
Kind ____
Part of body ____

7a. Were any operations performed on -- during this stay in the hospital (nursing home)?

[] Y
0 [] N (8)

b. What was the name of the operation? If name of operation is not known, describe what was done. ________

c. Any other operations during this stay?

[] Y (Describe) ____
[] N

The following questions are about the bill for this hospital stay -- not about any separate bill from the doctor or surgeon. Please look at this card (Show Card H).
Card H

1. Total or partial payment by self or family.
2. Social Security Medicare
3. Hospital insurance or Doctor Visit insurance
4. Workmen's compensation
5. Accident insurance carried by family or someone outside the family
6. Armed Forces Dependent Care (CHAMPUS)
7. Veteran's Benefits
8. Medicaid
9. Welfare
10. Other (Some other source)

8a. Which of these sources paid or will pay any of this hospital bill?

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10 (Specify) ____

b. Did or will any other source pay any of this hospital bill?

1 [] Y
2 N (d)

c. Which source?

Circle additional sources in 8a. Reask 8b and c

[] "1" is circled in 8a (e)
[] "1" is not circled in 8a (d)

d. Did or will you or your family pay any part of this hospital bill out of you own pocket?

1 [] Y
2 [] N (f)

e. How much of this hospital bill did or will you or your family pay out of your own pocket?

If hospital insurance reported ("3" circled in 8a), ask:

f. What part of the hospital bill was or will be paid by hospital insurance, less than half or on half or more?

1 [] Less than half (9)
2 [] 1/2 or more

If only "3" is circled in 8a, ask:

g. Did or will hospital insurance pay all of the hospital bill?

1 [] Y
2 [] N

9. NOTE: If the condition in Q. 6 or 7 is in Q. 38 or 39 or there is "1" or more nights in Q. 5b, a Condition page is required. If there is no Condition page, fill one after completing columns for all required hospitalizations.