[p. 58]
[] SP
1a. What is the name of the head of this household? -- Enter name in first column.
Last Name ____
b. What are the names of all other persons who live here? -- List all persons who live here. ____
c. I have listed (Read names.) Is there anyone else staying here now, such as friends, relatives, or roomers?
[] No
d. Have I missed anyone who USUALLY lives here but is now away from home?
[] No
e. Do any of the people in this household have a home anywhere else?
[] No
* Apply household membership rules.
If any adult males listed, ask:
f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States?
Col(s). ____ (Delete)
2 [] N
2. How is -- related to -- (Head of Household)?
HEAD
3. What is --'s date of birth? (Enter date and Age and circle Race and Sex)
Date ____
Year ____
RACE ____
2 [] B
3 [] OT
2 [] F
C
1. Record the number of Doctor Visits, Hospitalizations.
Doctor ____ (NP)
HOSP. ____ (NP)
WORK LOSS
[] 1+ days (7)
2. Record each condition in the person's column, with the question number(s) where it was reported.
2-week period ____, ____
Dentist and Doctor visit probe ____
Hospital probe ____
Injury probe ____
Q. no. ____
Condition ____
[MK Note: End section C]
Refer to Flashcard ____ to determine Sample Persons; mark SP boxes.
H
If related persons 17 years old or over are listed in addition to the respondent, say:
We would like to have all adults who are at home take part in the interview. Is your --, your --, etc., at home now? If "Yes" ask: Please ask them to join us.
1 [] At home
2 [] Not at home
[MK Note: End section H]
This survey is being conducted to collect information on the Nation's health. I will ask about visits to doctors and dentists, illness in the family, and other health related items. (Hand Calendar)
The next few questions refer to the past 2 weeks, the 2 weeks outlined in red on that calendar, beginning Monday, (date), and ending this past Sunday, (date).
4a. During those 2 weeks, did -- stay in bed because of any illness or injury?
00 [] N (If age: 17+ (5), 6-16 (6), Under 6 (8))
b. During that 2-week period, how many days did -- stay in bed all or most of the day?
5. During those 2 weeks, how many days did illness or injury keep -- from work? (For females): not counting work around the house.
00 [] None (8)
6. During those 2 weeks, how many days did illness or injury keep -- from school?
00 [] None (8)
If one or more days in 4b, ask 7; otherwise go to 8.
7. On how many of these -- days lost from
school]
did -- stay in bed all or most of the day?
00 [] None
lost from work
lost from school]
Were there any (other) days during the past 2 weeks that -- cut down on the things he usually does because of illness or injury?
2 [] N (9)
b. Again, not counting the day(s)
lost from work
lost from school]
During that period, how many (other) days did he cut down for as much as a day?
00 [] None
If 1 or more days in 4-8, ask 9; otherwise go to next person.
9a. What condition caused -- to
miss work
miss school
cut down]
during the past 2 weeks? Enter condition in item C. Ask 9b. ____
b. Did any other condition cause him to
miss work
miss school
cut down]
during that period?
[] N (NP)
c. What condition? Enter conditions in item C. Reask 9b. ____
10a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?
[] N (11)
b. Who was this? ____
Mark "Accident or injury" box in person's column
c. What was the injury? ____
d. Did anyone have any other accidents or injuries during that period?
[] N
If "Accident or injury," ask:
e. As a result of the accident, did -- see a doctor or did he cut down on the things he usually does?
[] N
[p. 59]
11a. During the past 2 weeks, did anyone in the family, that is you, your --, etc., go to a dentist?
[] N (12)
b. Who was this? ____
Mark "Dental visit" box in person's column.
c. During the past 2 weeks, did anyone else in the family go to a dentist?
[] N
If "Dental visit," ask:
d. During the past 2 weeks, how many times did -- go to dentist?
Do not ask for children 1 yr. old and under.
12a. During the past 12 months, (that is, since (date) a year ago), about how many visits did -- make to a dentist? (Include the -- visits you already told me about.)
Number of visits ____
b. ABOUT how long has it been since -- LAST went to a dentist?
2 [] Past 2 weeks not reported (11)
3 [] 2 weeks -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never
[p. 60]
13. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? Do not count doctors seen while a patient in a hospital.
Number of visits ____ (NP)
(Besides those visits)
14a. During that 2-week period did anyone in the family go to a doctor's office or clinic for shots, X-rays, tests, or examinations?
[] N (15)
b. Who was this? ____
Mark "Doctor visit" box in person's column.
c. Anyone else?
[] N
If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?
15a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?
[] N (16)
b. Who was the phone call about? ____
Mark "Phone call" box in person's column.
c. Any calls about anyone else?
[] N
If "Phone call," ask:
d. How many telephone calls were made to get medical advice about --?
Fill item C, (DOCTOR), from 13-15 for all persons. Ask 16a for each person with visits in DOCTOR box.
16a. For what condition did -- see or talk to a doctor during the past 2 weeks?
[] Pregnancy (16e)
[] No condition
b. Did -- see or talk to a doctor about any specific condition?
[] N (NP)
c. What condition? ____
Enter condition in item C. Ask 16d.
d. During that period, did -- see or talk to a doctor about any other condition?
[] N (NP)
e. During the past 2 weeks was -- sick because of her pregnancy?
[] N (16d)
f. What was the matter? ____
Enter condition in item C (16d)
17a. During the past 12 months, (that is, since (date) a year ago,) about how many times did -- see or talk to a medical doctor? (Do not count doctors seen while a patient in a hospital.) (Include the -- visits you already told me about.)
000 [] None
Number of visits ____
b. ABOUT how long has it been since -- LAST saw or talked to a medical doctor?
2 [] Past 2 weeks not reported (13 and 16)
3 [] 2 wks. -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never
[p. 61]
Ages 17+
18a. What was -- doing MOST OF THE PAST 12 MONTHS -- (For males): working or doing something else? (For females): keeping house, working or doing something else?
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)
If "something else," ask:
b. What was -- doing? ____
If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired? ____
d. If "retired," ask: Did he retire because of his health? ____
Ages 6-16
19a. What was -- doing MOST OF THE PAST 12 MONTHS -- going to school or doing something else?
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)
If "something else," ask:
b. What was -- doing? ____
0 [] Under 1 (21)
20a. Is -- able to take part at all in ordinary play with other children?
1 [] N (27)
b. Is he limited in the kind of play he can do because of his health?
[] N
c. Is he limited in the amount of play because of his health?
[] N (26)
21a. Is -- limited in any way because of his health?
5 [] N (NP)
b. In what way is he limited? Record limitation, not condition. ________ (27)
22a. Does -- health now keep him from working?
[] N
b. Is he limited in the kind of work he could do because of his health?
[] N
c. Is he limited in the amount of work he could do because of his health?
[] N
d. Is he limited in the kind or amount of other activities because of his health?
[] N (26)
23a. Does -- NOW have a job?
[] N
b. In terms of health, is -- NOW able to (work -- keep house) at all?
1 [] N (27)
c. Is he limited in the kind of (work -- housework) he can do because of his health?
[] N
d. Is he limited in the amount of (work -- housework) he can do because of his health?
[] N
e. Is he limited in the kind or amount of other activities because of his health?
[] N (26)
24. In terms of health would -- be able to go to school?
1 [] N (27)
25a. Does (would) -- have to go to a certain type of school because of his health?
[] N
b. Is he (would he be) limited in school attendance because of his health?
[] N
c. Is he limited in the kind or amount of other activities because of his health?
[] N
26a. Is -- limited in ANY WAY because of a disability or health?
5 [] N (NP)
b. In what way is he limited? Record limitation, not condition ________
been unable to --]
had to go to a certain type of school?
1 [] Mos. ____
2 [] Yrs. ____
b. What (other) condition causes this limitation? ____
If "old age" only, ask: Is this limitation caused by any specific condition? ____
Enter condition in item C. Ask 27c.
c. Is this limitation caused by any other condition?
[] N
Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?
Enter main condition ____
[p. 62]
28a. Was -- a patient in a hospital at any time since (date) a year ago?
[] N (Item C)
b. How many times was -- in a hospital since (date) a year ago?
29a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?
[] N (30)
b. Who was this? ____
Circle "Y" in person's column.
If "Y," ask:
c. During that period, how many times was -- in a nursing home or similar place?
Ask for each child 1 year old or under if date of birth is on or after reference date.
30a. Was -- born in a hospital?
If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 28b and item C.
If "Yes," and a hospitalization is entered for the mother and/or baby, ask 30b for each.
[] N (NP)
b. Is this hospitalization included in the number you gave me for --?
If "No," correct entries in 28 and item C for mother and/or baby.
[] N
31a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --
B. Any other gallbladder trouble? ____
C. Cirrhosis of the liver? ____
D. Fatty liver? ____
E. Hepatitis? ____
F. Yellow jaundice? ____
G. Any other liver trouble? ____
H. Diabetes? ____
I. Any disease of the pancreas? ____
J. Ulcer? ____
K. Hernia or rupture? ____
L. A disease of the esophagus? ____
M. Gastritis? ____
N. FREQUENT indigestion? ____
O. Any other stomach trouble? ____
P. Enteritis? ____
If "Yes," ask 31b and c.
b. Who was this? Enter name of condition and letter of line where reported in appropriate person's column in item C. ____
c. During the past 12 months, did anyone else have [conditions A-O]? ____
32. Compared to other persons --'s age, would you say that his health is excellent, good, fair, or poor?
2 [] G
3 [] F
4 [] P
R
Q.'s 4-32
For persons 17 years old or over, show who responded for (or was present during the asking of) Q.'s 4-32.
If persons responded for self, show whether entirely or partly. For persons under 17 show who responded for them.
2 [] Responded for self-partly
Person ____ was respondent
[MK Note: End section R]
[p. 70]
33a. What is the highest grade or year -- attended in school?
00 [] None (34)
Elem:
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 10
[] 11
[] 12
[] 2
[] 3
[] 4
[] 5
[] 6+
b. Did -- finish the -- grade (year)?
2 [] N
Ask for all males 17 years or over:
34a. Did -- ever serve in the Armed Forces of the United States?
2 [] N (35)
b. When did he serve? Circle code in descending order of priority. Thus if person served in Vietnam and in Korea, circle VN.
Korean War (June '50 - Jan. '55) . . . KW
World War II (Sept. '40 - July '47) . . . WWII
World War I (April '17 - Nov. '18) . . . WWI
Other Service (all other periods) . . . OS
2 [] KW
3 [] WWII
4 [] WWI
5 [] OS
9 [] DK
35a. Did -- work at any time last week or the week before -- not counting work around the house?
2 [] N
b. Even though -- did not work during these 2 weeks, does he have a job or business?
2 [] N
c. Was he looking for work or on layoff from a job?
2 [] N (36)
d. Which -- looking for work or on layoff from a job?
2 [] Layoff
3 [] Both
Ask for all persons with a "Yes" in 35a, b, or c.
If "Yes" in 35c only, questions 36a through 36d apply to this person's LAST full-time civilian job.
36a. For whom did -- work? Name of company, business, organization, or other employer. ____
b. What kind of business or industry is this? For example, TV and radio manufacturing, retail shoe store, State Labor Dept., farm. ____
c. What kind of work was -- doing? For example, electrical engineer, stock clerk, typist, farmer ____
d. What were --'s most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishes concrete. ____
Complete from entries in 36a-d; if not clear, ask:
e. Was --
F -- a FEDERAL government employee?
S -- a STATE government employee?
L -- a LOCAL government employee?
-- self-employed in OWN business, professional practice, or farm?
If not a farm, ask: Is the business incorporated?
SE -- No (or farm)
NEV -- NEVER WORKED
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV
[p. 71]
CARD I
$1,000 - $1,999 ... Group B
$2,000 - $2,999 ... Group C
$3,000 - $3,999 ... Group D
$4,000 - $4,999 ... Group E
$5,000 - $5,999 ... Group F
$6,000 - $6,999 ... Group G
$7,000 - $9,999 ... Group H
$10,000 - $14,999 ... Group I
$15,000 - $24,999 ... Group J
$25,000 and over ... Group K
37. Which of these income groups represents your total combined family income for the past 12 months - that is yours, your --'s etc.? Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rent from property, and so forth.
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K
38a. Which (other) family members received some income during the past 12 months? ____
Mark "Income" box in person's column.
If only one person with "Income" box marked, go to 40.
If 2 ore more persons with "Income" box marked, ask 39 for each:
39. Which of these income groups represents --'s income for the past 12 months?
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K
40. Is -- now married, widowed, divorced, separated, or never married?
1 [] Married -- spouse present
6 [] Married -- spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married