Appendix III. Questionnaire and Flash Cards
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
Special place ____
6a. What is your exact address? (Include House No., Apt. No., or other identification and ZIP code) ________
ZIP code ____
Line No. _____
b. What is your mailing address and ZIP code? ________
ZIP code ____
c. Special place name ____
Type code ____
 After 4-1-70 (Go to Q. 9c, complete if required and end interview)
8. Type of living quarters
2  OTHER unit
GO TO PROBE PAGE 2
10. Land use
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?
 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?
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?
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?
5  N
13. How many rooms are in this -- (Unit)? Count the kitchen but not the bathroom
14. How many bedrooms are in this -- (Unit)? (If "None" describe in footnotes)
15. What is the telephone number here?
Area code _ _ _
Number _ _ _ _ _ _ _
16. Was this interview observed?
2  N
NOTE: Before leaving household, check that item 20 has an entry. Determine the best time for callbacks for Condition Supplements.
18. 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  Demolished
3  Merged
4  Outside segment
5  Built after April 1, 1970
5  Other (Specify)
19. Record of calls (Rows 1-6)
20. List column numbers of family members requiring telephone or personal callbacks for Condition supplements ____
21. Record of additional personal calls (Row 1-4)
22a. Number of telephone calls ____
b. Total telephone interview time ____
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
Line number ____
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.
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).
5. Are these (specify location) quarters for more than one group of people?
(If "Yes" fill one line for each group)
USE OR CHARACTERISTICS
6. Do the occupants of these (specify location) quarters live and eat with any other group of people?
Do these quarters in (specify location) have:
7. Direct access from the outside or through a common hall?
8. Complete kitchen facilities for this unit only?
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.)
NOTE: Be sure to continue interview for original sample unit.