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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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[p.59]


Appendix III. Questionnaire and Flash Cards

U.S. Department of Commerce
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.


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, 8, 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. Send Inter-Comm.


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 persons requiring callbacks. ____

[] None
Health habits ____
Diabetes ____

21. Record of additional 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 persons requiring callbacks.

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

[p. 77]

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) ____

After entering description or location:

* In Area Segment, go to (3)
* In other type of Segments,
-If living quarters are not within the same specific sample address (and structure, if Permit Segment) - STOP TABLE X
-Otherwise, go to (3)
3. If listed, enter sheet and line number, STOP Table X, and continue interview for original sample unit.

If unlisted,

-And Area Segment, go to (4)
-And another type of Segment, go to (5)
$ ____
L ____

4. If outside AREA SEGMENT boundary, mark box below, STOP and -

* Go to next line of Table X, if additional quarters determined.
OR
* 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.