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[p. 60]
[] SP
[] P

1a. What is the name of the head of this household? -Enter name in first column.

First Name ____
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?

[] Yes*
[] No

d. Have I missed anyone who USUALLY lives here but is now away from home?

[] Yes*
[] No

e. Do any of the people in this household have a home anywhere else?

[] Yes*
[] No

* Apply household membership rules.

f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States?

1 [] Y
Col(s). ____ (Delete)

2 [] N


2a. How is -- related to -- (Head of Household)?

Relationship ____

HEAD

If parent--child relationship in 2a and both parents in household, ask:
b. Are you and -- the natural parents of --, --, etc.? If "Yes," mark P box in "child's" column.


3. What is --'s date of birth? (Enter date and Age and circle Race and Sex)

AGE ____
RACE ____
1 [] W
2 [] B
3 [] OT
SEX
1 [] M
2 [] F
Month ____
Date ____
Year ____

C

1. Record the number of Bed Days, Doctor Visits, and Hospitalizations.

BED DAYS ____ (NP)
[] None (NP)
DV ____ (NP)
[] None (NP)
HOSP. ____ (NP)
[] None (NP)

2. Record each condition in the person's column, with the question number(s) where it was reported.

Reference dates
2-week period ____, ____.
12-month Bed Days, Doctor visit probe ____
Hospital 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.

0 [] Under 17
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?

[] Y (4b)
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?

Days ____ (If age: 17+ (5), 6-16 (6), Under 6 (8))

5. During those 2 weeks, how many days did illness or injury keep -- from work? (For females): not counting work around the house.

WL days ____ (7)
00 [] None (8)

6. During those 2 weeks, how many days did illness or injury keep -- from school?

SL days ____
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

[work
school]

did -- stay in bed all or most of the day?

Days ____
00 [] None

8a. NOT COUNTING the day(s)

[in bed
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?

1 [] Y
2 [] N (9)

b. Again, not counting the day(s)

[in bed
lost from work
lost from school]

During that period, how many (other) days did he cut down for as much as a day?

Days ____
00 [] None

If 1 or more days in 4-8, ask 9; otherwise go to next person.

9a. What condition caused -- to

[stay in bed
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

[stay in bed
miss work
miss school
cut down]

during that period?

[] Y
[] N (NP)

c. What condition? ____

Enter conditions in item C. Reask 9b.

Fill item C, (BED DAYS), from 4b for all persons.

10 a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?

[] Y
[] N (11)

b. Who was this? -- Mark "Accident or injury" box in person's column ____

[] Accident or injury

c. What was the injury? ____

d. Did anyone have any other accidents or injuries during that period?

[] Y (10b and c)
[] 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?

[] Y (Enter injury in Item C)
[] N

[p. 61]


11 a. During the past 2 weeks, did anyone in the family, that is you, your --, etc., go to a dentist?

[] Y
[] N (12)

b. Who was this? -- Mark "Dental visit" box in person's column. ____

[] Dental visit

c. During the past 2 weeks, did anyone else in the family go to a dentist?

[] Y (Reask 11b and c)
[] N

If "Dental visit," ask:
d. During the past 2 weeks, how many times did -- go to dentist?

No. of dental visits ____ (NP)


Do not ask for children 1 yr. old and under.

Mark box or ask:
12. ABOUT how long has it been since -- LAST went to a dentist?

1 [] 2--week dental visit (NP)
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. 62]


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.

00 [] None (NP)
Number of visits ____ (NP)

(Besides those visits)
14 a. 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?

[] Y
[] N (15)

b. Who was this? -- Mark "Doctor visit" box in person's column. ____

[] Doctor visit

c. Anyone else?

[] Y (14b and c)
[] N

If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?

Number of visits ____ (NP)

15a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (16)

b. Who was the phone call about? -- Mark "Phone call" box in person's column. ____

[] Phone call

c. Any calls about anyone else?

[] Y (Reask 15b and c)
[] N

If "Phone call," ask:

d. How many telephone calls were made to get medical advice about --?

Number of calls ____ (NP)

Fill item C, (DV), from 13-15 for all persons. Ask 16a for each person with visits in DV box.

16a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 16d)
[] Pregnancy (16e)
[] No condition

b. Did -- see or talk to a doctor about any specific condition?

[] Y
[] 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?

[] Y (16c)
[] N (NP)

e. During the past 2 weeks was -- sick because of her pregnancy?

[] Y
[] 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 [] Only when in hospital
000 [] None
Number of visits ____

b. ABOUT how long has it been since -- LAST saw or talked to a medical doctor? Include doctors seen while a patient in a hospital.

1 [] 2--week DV
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. 63]


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?

1 [] Working (23a)
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?

1 [] Working (23a)
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? ____


Ages under 6

0 [] 1-5 yrs. (20)
0 [] Under 1 (21)

20a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (27)

b. Is he limited in the kind of play he can do because of his health?

2 [] Y (27)
[] N

c. Is he limited in the amount of play because of his health?

2 [] Y (27)
[] N (26)

21a. Is -- limited in any way because of his health?

[] Y
5 [] N (NP)

b. In what way is he limited? Record limitation, not condition. ________ (27)

22a. Does -- health now keep him from working?

1 [] Y (27)
[] N

b. Is he limited in the kind of work he could do because of his health?

2 [] Y (27)
[] N

c. Is he limited in the amount of work he could do because of his health?

2 [] Y (27)
[] N

d. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N (26)

23a. Does -- NOW have a job?

[] Y (23c)
[] N

b. In terms of health, is -- NOW able to (work -- keep house) at all?

[] Y
1 [] N (27)

c. Is he limited in the kind of (work -- housework) he can do because of his health?

2 [] Y (27)
[] N

d. Is he limited in the amount of (work -- housework) he can do because of his health?

2 [] Y (27)
[] N

e. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N (26)

24. In terms of health would -- be able to go to school?

[] Y
1 [] N (27)

25a. Does (would) -- have to go to a certain type of school because of his health?

2 [] Y (27)
[] N

b. Is he (would he be) limited in school attendance because of his health?

2 [] Y (27)
[] N

c. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N

26a. Is -- limited in ANY WAY because of a disability or health?

4 [] Y
5 [] N (NP)

b. In what way is he limited? Record limitation, not condition ________


27 a. About how long has he

[been limited in --
been unable to --]

had to go to a certain type of school?

000 [] Less than 1 month
1 [] Mos. ____
2 [] Yrs. ____

b. What (other) condition causes this limitation? ____

[] Old age only (NP)

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?

[] Y (Reask 27b and c)
[] N

Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?

[] Only 1 condition
Enter main condition ____

[p. 64]

28a. Was -- a patient in a hospital at any time since (date) a year ago?

[] Y
[] N (Item C)

b. How many times was -- in a hospital since (date) a year ago?

Times ____ (Item C)

29a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (30)

b. Who was this? -- Circle "Y" in person's column. ____

[] Y

If "Y," ask:
c. During that period, how many times was -- in a nursing home or similar place?

Times ____ (Item C)

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?

[] Y
[] N (NP)

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.

b. Is this hospitalization included in the number you gave me for --?

[] Y
[] N

If "No," correct entries in 28 and item C for mother and/or baby.

31a. Does anyone in the family (you, your --, etc.) HAVE:

Missing fingers, hand or arm - toes, foot or leg? ____
A. Permanent stiffness or any deformity of the foot, leg, fingers, arm, or back? ____
B. Paralysis of any kind? ____

If "Yes," ask 31b and c.

b. Who is this? Enter name of condition and 31 or letter of line where reported in appropriate person's column in item C. ____

c. Does anyone else have [conditions listed above]? ____

32a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) HAVE --

C. Arthritis of any kind or Rheumatism? ____
D. Gout? ____
E. Lumbago? ____
F. Osteomyelitis? (os-tee-oh-my-uh-lite-iss) ____
G. A bone cyst or bone spur? ____
H. Any other disease of the bone or cartilage? ____
I. Trick knee? ____
J. A slipped or ruptured disc? ____
K. Curvature of the spine? ____
L. REPEATED trouble with neck, back, or spine? ____
M. Bursitis or Synovitis? (sin-uh-vite-iss) ____
N. Any disease of the muscles or tendons? ____

If "Yes," ask 31b and c.

b. Who is 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 of the bone and muscle]? ____
Conditions C-N and V are conditions of the bone and muscle.


33. Compared to other persons --'s age, would you say that his health is excellent, good, fair, or poor?

1 [] E
2 [] G
3 [] F
4 [] P

R

Q.'s 4-33

For persons 17+, show who responded for (or was present during the asking of) Q.'s 4-33.

If persons responded for self, show whether entirely or partly. For persons under 17 show who responded for them.

1 [] Responded for self--entirely
2 [] Responded for self--partly
Person ____ was respondent


[MK Note: End section R]

[p. 65]


[MK Note: The following appears to be a response sheet for questions 28a-b, 29b-c, and 30a-b. There are five columns in which to enter responses; only one is represented here as the information contained in each column is identical.]

28a.

[] Y
[] N (Item C)

b. _____ Times (Item C)

29b.

[] Y

c. _____ Times (Item C)

30a.

[] Y
[] N (NP)

b.

[] Y
[] N


[MK Note: End Response sheet]

32a. DURING THE PAST 12 MONTHS, did anyone in the family have -
Conditions O-U and W-Z are conditions of the skin.

O. A tumor, cyst or growth of the skin? ____
P. Eczema or psoriasis? (so-rye-uh-sis) ____
Q. TROUBLE with dry or itching skin? ____
R. TROUBLE with acne? ____
S. A skin ulcer? ____
T. Any kind of skin allergy? ____
U. Dermatitis or any other skin trouble? ____
V. TROUBLE with fallen arches, flatfeet or clubfoot? ____
W. TROUBLE with ingrown toenails or fingernails? ____
X. TROUBLE with bunions, corns, or calluses? ____
Y. A disease of the hair or scalp? ____
Z. Any disease of the lymph or sweat glands? ____

If "Yes," ask 32b and c

b. Who was this? Enter in item C. ____

c. During the past 12 months, did anyone else have [conditions of the skin]? ____


[MK Note: The following appears to be a response sheet for question 33 and section R. The response sheet has 5 columns labeled 2 through 6. Only one response column is represented here since the information contained in each is identical.

(Column 2-6)

33.

1 [] E
2 [] G
3 [] F
4 [] P
R
1 [] Responded for self-entirely
2 [] Responded for self-partly
Person ____ was respondent

[p.70.]

HEALTH INSURANCE PAGE

These next questions are about health insurance.
If 65+, ask: otherwise go to 2a,
1. Does -- have Medicare from Social Security?

[] Under 65 (NP)
1[] Covered (NP)
[] Not covered (NP)

2a. (In addition to Medicare) There is a public program called Medicaid which provides medical assistance to persons in need. During the past 12 months, has anyone in the family received medical care which has been or will be paid for by Medicaid?

[]Y
[]N (3)

b. Who was this? Mark "Covered" box in person's column.

1[] Covered

c. Anyone else?

[]Y (Reask 2b and c)
[]N

We are interested in all kinds of health insurance plans except those which pay for accidents.
3a. (Not counting Medicare) Is anyone in the family covered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill?

[] Y
[] N (3d)

b. What is the name of the plan? (Record in Table H.I.)

c. Is anyone in the family covered by any other hospital insurance plan?

[] Y (Reask 3b and c)
[] N

d. Is anyone in the family covered by any (other) health insurance plan which pays any part of a DOCTOR'S or SURGEON'S bill?

[] Y
[] N (4)

e. What is the name of the plan? (Record in Table H.I., reask 3d)

[p. 75]


If 17 years old or over, ask:
1a. What is the highest grade or year -- attended in school?

[] Und. 17 (NP)
00 [] None (2)

Elem.
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High
[] 9
[] 10
[] 11
[] 12
College:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

b. Did -- finish the -- grade (year)?

1 [] Y
2 [] N


2a. Did -- ever serve in the Armed Forces of the United States?

1 [] Y
2 [] N (3)

b. When did he serve? Circle code in descending order of priority. Thus if person served in Vietnam and in Korea, circle VN.

Vietnam Era (Aug. '64 to April '75) . . . VN
Korean War (June '50 - Jan. '55) . . . KW
World War II (Sept. '40 - July '47) . . . WWII
World War I (April '17 - Nov. '18) . . . WWI
Post Vietnam (May '75 to present) . . . PVN
Other Service (all other periods) . . . OS
1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] PVN
6 [] OS
9 [] DK


3a. Did -- work at any time last week or the week before -- not counting work around the house?

1 [] Y (4)
2 [] N

b. Even though -- did not work during these 2 weeks, does he have a job or business?

1 [] Y
2 [] N

c. Was he looking for work or on layoff from a job?

1 [] Y
2 [] N (4)

d. Which -- looking for work or on layoff from a job?

1 [] Looking
2 [] Layoff
3 [] Both


Ask for all persons with a "Yes" in 3a, b, or c.

If "Yes" in 3c only, questions 4a through 4e apply to this person's LAST full-time civilian job.

4a. 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 4a-d; if not clear, ask:

e. Was --

-- an employee of PRIVATE company, business, or individual for wages, salary, or commission? ......................................................................................................P
-- a FEDERAL government employee? ................................................................F
-- a STATE government employee? .......................................................................S
-- a LOCAL government employee? .....................................................................L
-- self-employed in OWN business, professional practice, or farm?
If not a farm, ask: Is the business incorporated?
Yes ..................................................................................................I
No (or farm) ................................................................................SE
-- working WITHOUT PAY in family business or farm? ................................WP
-- NEVER WORKED .....................................................................................NEV
Class of worker
1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV

[p. 76]


Hand card O
CARD O

National Origin or Ancestry
01 Countries of Central or South America
02 Chicano
03 Cuban
04 Mexican
05 Mexicano
06 Mexican-American
07 Puerto Rican
08 Other Spanish
09 Other European, such as German, Irish, English, French
10 Black, Negro, or Afro-American
11 American Indian or Alaskan Native
12 Asian or Pacific Islander, such as Chinese, Japanese, Korean, Philippino, Samoan
OR
Another group not listed - Specify
If 17+, ask:
5a. Which of those groups BEST describes --'s national origin or ancestry?

0 [] Under 17 (NP)
(Enter precode) ____

If multiple entries, ask:

b. Which of those groups, that is, (entries in 5a) would you say BEST describes --'s national origin or ancestry?

(Specify) ____


If 17+, ask:
6. Is -- now married, widowed, divorced, separated, or never married?

0 [] Under 17
1 [] Married -- spouse present
6 [] Married -- spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married


Hand Card I

CARD I
Under $1,000 (including loss) ... Group A
$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

7. 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.

00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K

8a. Which (other) family members received some income during the past 12 months? ____
Mark "Income" box in person's column.

[] Income

If only one person with "Income" box marked, go to 10.
If 2 ore more persons with "Income" box marked, ask 9 for each:

9. Which of these income groups represents --'s income for the past 12 months?

00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K

10a. Does anyone in this family receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?

[] Y
[] N (11)

b. Which (other) family members are included in the AFDC assistance payment? Mark "AFDC" box in each person's column. ____

1 [] AFDC

c. Are any other family members included in this program?

[] Y (Reask 10b and c)
[] N

11a. Does anyone in this family receive the "Supplemental Security Income" or "SSI" gold-colored check?

[] Y
[] N (Page 1)

b. Who receives this check? Mark box in person's column. ____

1 [] SSI

c. Anyone else?

[] Y (Reask 11b and c)
[] N