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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.



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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
[] Cen - Sup
[] 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. Is this your mailing address? Mark box or specify if different. Include ZIP code. ________

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

c. Special place name ____

Sample unit number ____
Type code ____

7. YEAR BUILT

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

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 11.
-- Special Place units not coded 85-88 in 6c. go to 13.

11. Do you own or rent this place?

[] Own
[] Rent
[] Rent for free

12a. Does the place you (own, rent, rent for free) have 10 acres or more?

1 [] Y (12b)
2 [] N (12c)

b. During the past 12 months did sales of crops, livestock, and other farm products form this place amount to $50 or more?

1 [] Y (13)
2 [] 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?

1 [] Y
2 [] N


13. How many rooms are in this [unit]? Count the kitchen but not the bathroom

Rooms ____


14. How many bedrooms are in this [unit]? If "None" describe in footnotes
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 20a AND b HAVE AN ENTRY. Determine the best time for callbacks for Condition Supplements and sample persons.


18. Noninterview reason

Type A
1 [] Refusal -- Describe in a footnote
2 [] No one at home -- repeated calls
3 [] Temporarily absent - Footnote
4 [] Other (Specify) ____


Fill items 1-10, 12a-c as applicable, 16-19

Type B
1 [] Vacant -- nonseasonal
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____

Fill items 1-10, 12a-c as applicable, 16-19.

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

Fill items 1-6a, 6c if required, 9c if marked, 16-19


19. Record of calls [Rows 1-6]

Month ____
Date ____
Beginning time ____
[] a.m.
[] p.m.
Ending time ____
[] a.m.
[] p.m.
Comp ____

20a. List column numbers of sample persons not interviewed during initial interview.

[] None
Col. No. ____
Cond. Supp. ____
[] Y
[] N
2 wk. DV
[] Y
[] N
H-M.C.
[] Y
CE
[] Y
[] N

b. List column numbers of nonsample persons requiring telephone callbacks for Condition Supplements. ____

[] None

21. Record of additional personal calls
[Rows 1-3]

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

NOTE: Footnote reason for noninterview for sample persons in same detail as in item 18.

22a. Number of telephone calls ____

b. Total telephone interview time ____