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[p.57]


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. R.O. 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
[] Do NOT 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)


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 ____


14. How many bedrooms are in this [unit]? If "None" describe in footnotes ____


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 for 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 1-6a, 7-10, 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 1-6a, 7-10, 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 1-8]

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

20a. List column numbers of sample persons requiring callbacks. ____

[] None

21. Record of telephone calls

[Rows 1-3]

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

22. Enter reason for noninterviews for sample persons.

1 [] Refusal (Specify) ____
2 [] No one at home -- repeated calls
3 [] Temporarily absent (Specify) ____
4 [] Other (Specify) ____

[p. 72]

E

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

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.

$ ____
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?

[] Yes
[] No

8. Complete kitchen facilities for this unit only?

[] Yes
[] No

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.