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[p.58]


Appendix III. Questionnaire and Flash Cards

U.S. Department of Commerce
Social and Economic Statistics Administration
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service

U.S. Health Interview Survey

1. Book _____ of _____ books

2. DCC number ____

3. Sample ____

4. Segment type

Area ____
Permit ____
Address ____
Special place ____

5. Control number

PSU ____
Segment ____
Serial ____

6a. What is your exact address? (Include House No., Apt. No., or other identification and ZIP code) ________

City ____
State ____
ZIP code ____

Listing Sheet

Sheet No. _____
Line No. _____

b. What is your mailing address and ZIP code? ________

[] Same as 6a
City ____
State ____
ZIP code ____

c. Special place name ____

Sample unit number ____
Type code ____

7. Year built

[] Do NOT Ask
[] Ask:
When was this structure originally built?
[] Before 4-1-70 (Continue interview)
[] After 4-1-70 (Go to Q. 9c, complete if required and end interview)


8. Type of living quarters

1 [] Housing unit
2 [] OTHER unit

9. Area segments ONLY

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

GO TO PROBE PAGE 2


10. Land use

2 [] RURAL
1 [] URBAN (13)
-- Regular units and Special Place units coded 85-88 in 6c. go to Q. 11.
-- Special Place units not coded 85-88 in 6c. go to Q 13.


11. Do you own or rent this place?
[] Owned
[] Rented
[] Rented for free


12a. You told me your living quarters are (owned, rented, rented for free). Does the place you (own, rent, rent for free) have 10 acres or more?
1 [] Y (b)
2 [] N (c)


b. During the past 12 months did sales of crops, livestock, and other farm products form this place amount to $50 or more?
2 [] Y (13)
4 [] N (13)


c. During the past 12 months did sales of crops, livestock, and other farm products from this place amount to $250 or more?
3 [] Y
5 [] N


13. How many rooms are in this -- (Unit)? Count the kitchen but not the bathroom

Total Rooms ____


14. How many bedrooms are in this -- (Unit)? (If "None" describe in footnotes)

Number of bedrooms ____


15. What is the telephone number here?

2 [] None
Area code _ _ _
Number _ _ _ _ _ _ _

16. Was this interview observed?

1 [] Y
2 [] N

17. Interviewer's name ____

Code ____

NOTE: Before leaving household, check that item 20 has an entry. Determine the best time for callbacks for Condition Supplements.


18. 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 [] Unused line of listing sheet
2 [] Demolished
3 [] Merged
4 [] Outside segment
5 [] Built after April 1, 1970
5 [] Other (Specify)


19. Record of calls (Rows 1-6)

Date ____
Beginning time

____ a.m.
____ p.m.

Ending time

____ a.m.
____ p.m.

Comp ____

20. List column numbers of family members requiring telephone or personal callbacks for Condition supplements ____

[] NONE

21. Record of additional personal calls (Row 1-4)

Date ____
Beginning time
____ a.m.
____ p.m.
Ending time
____ a.m.
____ p.m.
Col. Nos. completed

22a. Number of telephone calls ____

b. Total telephone interview time ____

[p. 76]

E

If this questionnaire is for an extra unit, enter Control Number of original sample ____

If in AREA SEGMENT, also enter FIRST unit listed on property

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

1. Line No. [1-3]

LOCATION OF UNIT

2. Where are these quarters located? ____

(Enter exact description or location, e.g., basement, 2nd floor, rear)

3. If listed, enter sheet and line number, STOP Table X, and continue interview for original sample unit.
If unlisted, go to 4.

S ____
L ____

4. If outside AREA SEGMENT boundary, mark box below, STOP Table X, and go to Household Page, item 9, or Probe page, question 1 (as applicable).

[] Outside segment boundary

5. Are these (specify location) quarters for more than one group of people?
(If "Yes" fill one line for each group)

[] Yes
[] No

USE OR CHARACTERISTICS

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

[] Yes -- Go to 9 and circle N
[] No

All Quarters
Do these quarters in (specify location) have:

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

[] Y
[] N

8. Complete kitchen facilities for this unit only?

[] 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

NOTE: Be sure to continue interview for original sample unit.