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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


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]


If 17+, ask:
4. 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

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).

5a. During those 2 weeks, did -- stay in bed because of any illness or injury?

[] Y (5b)
00 [] N (If age: 17+ (6), 6-16 (7), Under 6 (9))

b. During that 2-week period, how many days did -- stay in bed all or most of the day?

Days ____ (If age: 17+ (6), 6-16 (7), Under 6 (9))

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

WL days ____ (8)
00 [] None (9)

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

SL days ____
00 [] None (9)

If one or more days in 5b, ask 8; otherwise go to 9.

8. On how many of these -- days lost from

[work
school]

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

Days ____
00 [] None

9a. 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 (10)

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 one or more days in 5-9, ask 10 otherwise go to next person.

10a. What condition caused -- to

[stay in bed
miss work
miss school
cut down]

during the past 2 weeks? ____

Enter condition in item C. Ask 10b.

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 condition in item C (10b)

Fill item C, (BED DAYS), from 5b for all persons.

[p. 61]


[MK Note: Page 61 appears to be a response sheet for questions asked on page 60. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

4.

0 [] Under 17
1 [] Married - spouse present
6 [] Married - spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married
H
0 [] Under 17
1 [] At home
2 [] Not at home

5a.

[] Y (5b)
00 [] N (If age: 17+ (6), 6-16 (7), Under 6 (9))

b. Days ____ (If age: 17+ (6), 6-16 (7), Under 6 (9))

6.

WL days ____ (8)
00 [] None (9)

7.

SL days ____
00 [] None (9)

8.

Days ____
00 [] None

9a.

1 [] Y
2 [] N (10)

b.

Days ____
00 [] None

10a. Enter condition in item C. Ask 10b.

b.

[] Y
[] N (NP)

c. Enter condition in item C (10b)

Fill item C, (BED DAYS), from 5b for all persons.

[p. 62]

11a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?

[] Y
[] N (12)

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 (11b 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


12a. During the past 2 weeks, did anyone in the family go to a dentist?

[] Y
[] N (13)

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 12b 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:
13. ABOUT how long has it been since -- LAST went to a dentist?

1 [] 2--week dental visit
2 [] Past 2 weeks not reported (12)
3 [] 2 weeks -- 6 months
4 [] Over 6 -- 12 months
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[p. 63]

[MK Note: Page 63 appears to be a response sheet for questions asked on page 62. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

11b.

[] Accident or injury

c. Injury ____

e.

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

12b.

[] Dental visit

d. No. of dental visits ____ (NP)

13.

1 [] 2--week dental visit
2 [] Past 2 weeks not reported (12)
3 [] 2 weeks -- 6 months
4 [] Over 6 -- 12 months
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[p. 64]


14. 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)
15a. 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 (16)

b. Who was this? ____

Mark "Doctor visit" box in person's column.

[] Doctor visit

c. Anyone else?

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

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

Number of visits ____ (NP)

16a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (17)

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 16b 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 14-16 for all persons. Ask 17a for each person with visits in DV box.

17a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 17d)
[] Pregnancy (17e)
[] 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 17d.

d. During that period, did -- see or talk to a doctor about any other condition?

[] Y (17c)
[] N (NP)

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

[] Y
[] N (17d)

f. What was the matter? ____

Enter condition in item C (17d)


18a. 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 (14 and 17)
3 [] 2 wks. -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[p. 65]

[MK Note: Page 65 appears to be a response sheet for questions asked on page 64. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

14.

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

15b.

[] Doctor visit

d. Number of visits ____ (NP)

16b.

[] Phone call

d. Number of calls ____ (NP)

17a.

[] Condition (item C THEN 17d)
[] Pregnancy (17e)
[] No condition

b.

[] Y
[] N (NP)

c. Enter condition in item C. Ask 17d.

d.

[] Y (17c)
[] N (NP)

e.

[] Y
[] N (17d)

f. Enter condition in item C (17d)

18a.

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

b.

1 [] 2--week DV
2 [] Past 2 weeks not reported (14 and 17)
3 [] 2 wks. -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[p. 66]


Ages 17+
19a. 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 (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

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
20a. What was -- doing MOST OF THE PAST 12 MONTHS - going to school or doing something else?

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

If "something else," ask:
b. What was -- doing? ____

Ages under 6

0 [] 1-5 yrs. (21)
0 [] Under 1 (22)


21a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (28)

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N (27)

22a. Is -- limited in any way because of his health?

[] Y
5 [] N (NP)

b. In what way is he limited? Record limitation, not condition. ________ (28)

23a. Does -- health now keep him from working?

1 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N (27)

24a. Does -- NOW have a job?

[] Y (24c)
[] N

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

[] Y
1 [] N (28)

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N (27)

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

[] Y
1 [] N (28)

26a. Does (would) -- have to go to a certain type of school because of his health?

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N

27a. 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 ________


28a. 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? ____

If "old age" only, ask: Is this limitation caused by any specific condition? ____

Enter condition in item C. Mark D box, THEN 28c

[] Old age only, Mark D box, THEN (NP)

c. Is this limitation caused by any other condition?

[] Y (Reask 28b 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. 67]

[MK Note: Page 67 appears to be a response sheet for questions asked on page 66. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

19.

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

0 [] 1-5 yrs. (21)
0 [] Under 1 (22)

20.

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

0 [] 1-5 yrs. (21)
0 [] Under 1 (22)

21a.

[] Y
1 [] N (28)

b.

2 [] Y (28)
[] N

c.

2 [] Y (28)
[] N (27)

22a.

[] Y
5 [] N (NP)

b. ____ (28)

23a.

1 [] Y (28)
[] N

b.

2 [] Y (28)
[] N

c.

2 [] Y (28)
[] N

d.

3 [] Y (28)
[] N (27)

24a.

[] Y (24c)
[] N

b.

[] Y
1 [] N (28)

c.

2 [] Y (28)
[] N

d.

2 [] Y (28)
[] N

e.

3 [] Y (28)
[] N (27)

25.

[] Y
1 [] N (28)

26a.

2 [] Y (28)
[] N

b.

2 [] Y (28)
[] N

c.

3 [] Y (28)
[] N

27a.

4 [] Y
5 [] N (NP)

b. ____

28a.

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

b. Enter condition in item C. Mark D box, THEN 28c

[] Old age only, Mark D box, THEN (NP)

c.

[] Y (Reask 28b and c)
[] N

d.

[] Only 1 condition
Enter main condition ____

[p. 68]

29a. 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)

30a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (31)

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.
31a. Was -- born in a hospital?

[] Y
[] N (NP)

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 29b and item C.

If "Yes," and a hospitalization is entered for the mother and/or baby, ask 31b for each.

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

[] Y
[] N

If "No," correct entries in 29 and item C for mother and/or baby.

32a. Does anyone in the family (you, your --, etc.) HAVE-

A. Deafness in one or both ears? ____
B. Any other trouble hearing with one or both ears? ____
C. Tinnitus or ringing in the ears? ____
D. Blindness in one or both eyes? ____
E. Cataracts? ____
F. Glaucoma? ____
G. Color blindness? ____
H. A detached retina or any other condition of the retina? ____
I. Any other trouble seeing with one or both eyes even when wearing glasses? ____
J. A cleft palate or harelip? ____
K. Stammering or stuttering? ____
L. Any other speech defect? ____
M. A missing finger, hand, or arm, toe, foot, or leg? ____
N. A missing (breast), kidney or lung? ____

If "Yes," ask 32b 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. Does anyone else have [conditions A-N]? ____


33a. Does anyone in the family use -

1. Eyeglasses? ____
2. Contact lenses? ____
3. A hearing aid? ____

If "Yes," ask 33b and c

b. Who is this? ____

Mark box in person's column

1 [] Eyeglasses
2 [] Contact lenses
3 [] Hearing aid (Item C)

c. Anyone else? ____

For "hearing aid," with no hearing problem reported, enter "33, hearing trouble," in item C2


34. 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 4-34

For persons 17 years or over, show who responded for (or was present during the asking of) Questions 4-34.

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. 69]

[MK Note: The following appears to be a response sheet for questions 29a-b, 30b-c, and 31a-b. There are five columns in which to enter responses; only one is represented here as the information contained in each column is identical.]

29a.

[] Y
[] N (Item C)

b. Times ____ (Item C)

30b.

[] Y

c. Times ____ (Item C)

31a.

[] Y
[] N (NP)

b.

[] Y
[] N


[MK Note: End Response sheet]

32a. Does anyone in the family NOW have-

O. Palsy or cerebral palsy? ____
P. Paralysis of any kind? ____
Q. Curvature of the spine? ____
R. REPEATED trouble with back or spine? ____
S. Any TROUBLE with fallen arches or flatfeet? ____
T. A clubfoot? ____
U. Permanent stiffness or any deformity of the back, foot, or leg? ____
V. Permanent stiffness or any deformity of the fingers, hand, or arm? ____
W. Mental retardation? ____
X. Any condition caused by an old accident, or injury? ____
If "Yes," ask: What is the condition? ____
Y. Epilepsy? ____
Z. REPEATED convulsions, seizures, or blackouts? ____

If "Yes," ask 32 b 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. Does anyone else have [conditions O-Z]? ____


[MK Note: The following appears to be a response sheet for questions 33b, 34, and R. There are five columns in which to enter responses; only one is represented here as the information contained in each column is identical.]

33b.

1 [] Eyeglasses
2 [] Contact lenses
3 [] Hearing aid (Item C)

[Columns 2-6]

34.

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

R

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

[MK Note: End response sheet]

[p. 74]

BD

Mark box(es) for item C.

1 [] 1+ Bed Days
2 [] 1+ Hospital Stays
3 [] No Bed Days

45. During the past 12 months (that is since (date) a year ago), ABOUT how many days did illness or injury keep -- in bed all or most of the day?
(Include the days in the past 2 weeks.) (Include the days while a patient in a hospital.)
(Was it more than 7 days or less than 7 days?)
(Was it more than 30 days or less than 30 days?)
(Was it more than half the year or less than half the year?)

0 [] None
1 [] 1--7
2 [] 8--30
3 [] 31--180 (6 months)
4 [] 181+ (6 months +)

46a. Does anyone in the family now use (any of the following special aids) -

1. An artificial arm?
[] Yes
[] No
2. An artificial leg?
[] Yes
[] No
3. A brace of any kind?
[] Yes
[] No
4. Crutches?
[] Yes
[] No
5. A cane or walking stick?
[] Yes
[] No
6. Special shoes?
[] Yes
[] No
7. A wheel chair?
[] Yes
[] No
8. A walker?
[] Yes
[] No
9. Guide dog?
[] Yes
[] No
10. Any other kind of aid for getting around?
[] Yes
[] No

If "Yes," specify: ____Enter in Table SA

b. Who is this? ____

c. Anyone else? ____

Table SA
[Rows 1-5]

a. Person No. ____

b. Type of aid ____

If 1-6 in (b), ASK:

c. Does he use one or two ____ (at a time)?

[] 1
[] 2
[] Other

If 3-10 in (b), ASK:

d. For what condition does he need this ____? (Item C)
If "brace," Ask: On what part of the body is the brace worn? ____

[p. 75]


[MK Note: Page 75 appears to be a response sheet for questions asked on page 74. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

BD

1 [] 1+ Bed Days
2 [] 1+ Hospital Stays
3 [] No Bed Days

45.

0 [] None
1 [] 1--7
2 [] 8--30
3 [] 31--180 (6 months)
4 [] 181+ (6 months +)

[MK Note: End response sheet]

Table SA - Continued
[Rows 1-5]

e. Is the ____ used all of the time, most of the time or only occasionally?

1 [] All
2 [] Most
3 [] Occasionally

f. How long has he used ____?

[] Less than 1 month
[] Months ____
[] Years ____

g. How was the _____ obtained? Was it purchased, rented, borrowed or a gift?

1 [] Purchased
2 [] Rented
3 [] Borrowed
4 [] Gift

[p. 86]


R4

1 [] Not SP or SP under 19 (NP)
2 [] SP 19+ callback required (NP)
3 [] SP 19+ available (6-13)


6. On the average, how many hours of sleep do you usually get at night?

Hours ____


7. How often do you eat breakfast - almost every day, sometimes, rarely or never?

1 [] Everyday
2 [] Sometimes
3 [] Rarely or never
[] Other -- Specify ____


8. Including evening snacks, how often do you eat between meals - almost every day, sometimes, rarely or never?

1 [] Everyday
2 [] Sometimes
3 [] Rarely or never
[] Other -- Specify ____


9. Would you say that you are physically more active, less active or about as active as other persons your age?

1 [] More active
2 [] Less active
3 [] Same
[] Other -- Specify ____


10a. How often do you drink wine - never, occasionally, once or twice a week, or more than twice a week?

1 [] Never
2 [] Occasionally (10d)
3 [] Once or twice (10d)
4 [] More (10d)


b. How often do you drink beer - never, occasionally, once or twice a week, or more than twice a week?

1 [] Never
2 [] Occasionally (10d)
3 [] Once or twice (10d)
4 [] More (10d)


c. How often do you drink liquor - never, occasionally, once or twice a week, or more than twice a week?

1 [] Never
2 [] Occasionally
3 [] Once or twice
4 [] More

If all "Never," go to 11


d. When you drink --, how many drinks do you usually have at one sitting?

Wine ____ (10b)
Beer ____ (10c)
Liquor ____


If under 5 in 10d ask; otherwise go to 11

e. On any one occasion during the past 12 months, did you have 5 or more drinks of (wine/beer/liquor)?

1 [] Y
2 [] N


11a. Have you smoked at least 100 cigarettes in your entire life?

1 [] Y
2 [] N (12)

b. Do you smoke cigarettes now?

1 [] Y
2 [] N (12)


c. On the average, ABOUT how many cigarettes a day do you smoke? ____


12a. About how tall are you without shoes?

Feet ____
Inches ____

b. About how much do you weigh without clothes or shoes? ____


13a. During the past 12 months, have you had any problems getting medical care for yourself (for any of the following reasons) --

1. Because care was not available when you needed it?
[] Y (b)
[] N

2. Because of how much it cost?
[] Y (b)
[] N

3. Because you didn't know where to go?
[] Y (b)
[] N

4. Because you didn't have a way to get there?
[] Y (b)
[] N

5. Because the hours weren't convenient?
[] Y (b)
[] N


b. Did this problem PREVENT you from getting medical care for yourself?

1. Because care was not available when you needed it?
1[] Y
2[] N

2. Because of how much it cost?
1[] Y
2[] N

3. Because you didn't know where to go?
1[] Y
2[] N

4. Because you didn't have a way to get there?
1[] Y
2[] N

5. Because the hours weren't convenient?
1[] Y
2[] N

[p. 87]


[MK Note: Page 87 contains a response sheet for questions asked on page 86. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]

R4

1 [] Not SP or SP under 19 (NP)
2 [] SP 19+ callback required (NP)
3 [] SP 19+ available (6-13)
6. Hours ____

7.

1 [] Everyday
2 [] Sometimes
3 [] Rarely or never
[] Other -- Specify ____

8.

1 [] Everyday
2 [] Sometimes
3 [] Rarely or never
[] Other -- Specify ____

9.

1 [] More active
2 [] Less active
3 [] Same
[] Other -- Specify ____

10a.

1 [] Never
2 [] Occasionally (10d)
3 [] Once or twice (10d)
4 [] More (10d)

b.

1 [] Never
2 [] Occasionally (10d)
3 [] Once or twice (10d)
4 [] More (10d)

c.

1 [] Never
2 [] Occasionally
3 [] Once or twice
4 [] More

d.

Wine ____ (10b)
Beer ____ (10c)
Liquor ____

e.

1 [] Y
2 [] N

11a.

1 [] Y
2 [] N (12)

b.

1 [] Y
2 [] N (12)

c. Cigarettes ____

12a.

Feet ____
Inches ____

b. Pounds ____

13a.
[1-5]

a. Had problem

[] Y (b)
[] N

b. Prevented care

1 [] Y
2 [] N

13b.
[1-5]

a. Had problem

[] Y (b)
[] N

b. Prevented care

1 [] Y
2 [] N

[p. 90]


If 17+, 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


c. Does -- have a service connected disability?

1 [] Y
2 [] N


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. [Occupation] ____

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
1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV

[p. 91]


[MK Note: Page 91 has a response sheet for questions asked on page 90. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

1a.

[] 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.

1 [] Y
2 [] N

2a.

1 [] Y
2 [] N (3)

b.

1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] PVN
6 [] OS
9 [] DK

c.

1 [] Y
2 [] N

3a.

1 [] Y (4)
2 [] N

b.

1 [] Y
2 [] N

c.

1 [] Y
2 [] N (4)

d.

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

4a. Employer ____

b. Industry ____

c. Occupation ____

d. Duties ____

e. Class of worker

1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV


[MK Note: End response sheet]

[p. 92]


If 17+, ask:
5a. During the past 12 months, about how many months did you have a job?

[] Under 17 (NP)
00 [] None (NP)
Months ____
12 [] Entire year

b. During that period, ABOUT how many days did illness or injury keep -- from work -- not counting work around the house?

[] None
Days ____
Months ____


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 -- European, except Spanish (such as German, Irish, English, French and all other European countries)
10 -- Black, Negro, or Afro-American
11 -- American Indian or Alaskan Native
12 -- Asian or Pacific Islander, such as Chinese, Japanese, Korean, Filipino, Samoan
OR
Another group not listed -- Specify

If 17+, ask:
6a. 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 6a) would you say BEST describes --'s national origin or ancestry? (Specify) ____

7a. During the past 12 months, has anyone in the family received medical care which has been or will be paid for by MEDICARE?

[] Y
[] N (8)

b. Who was this? ____

Mark "Medicare" in person's column.

1 [] Medicare

c. Anyone else?

[] Y (Reask 7b and c)
[] N

8a. 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 (9)

b. Who was this? ____

Mark "Medicaid" in person's column.

1 [] Medicaid

c. Anyone else?

[] Y (Reask 8b and c)
[] N


9a. During the past 12 months, has anyone in the family received medical care provided or paid for by the Veterans Administration?

[] Y
[] N (10)

b. Who was this? ____

Mark "VA" in person's column.

1 [] VA

c. Anyone else?

[] Y (Reask 9b and c)
[] N

[p. 93]


[MK Note: Page 93 contains a response sheet for questions asked on page 92. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

5a.

[] Under 17 (NP)
00 [] None (NP)
Months ____
12 [] Entire year

b.

[] None
Days ____
Months ____

6a.

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

b. (Specify) ____

7b.

1 [] Medicare

8b.

1 [] Medicaid

9b.

1 [] VA


[MK Note: End response sheet]

[p. 94]


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

10. 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

11a. Which (other) family members received some income during the past 12 months? ____

Mark "Income" box in person's column.

[] Income

b. Did any other family members receive any income during the past 12 months?

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

If only one person with "Income" box marked, go to 13.

If 2 ore more persons with "Income" box marked, ask 12 for each:

12. 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


13a. During the past 12 months, did anyone in the family receive any payments or benefits from Workmen's Compensation?

[] Y
[] N (14)

b. Who was this? ____

Mark "Workmen's Compensation" box in person's column.

1 [] Workmen's Compensation

c. Anyone else?

[] Y (Reask 13b and c)
[] N


14a. During the past 12 months, did anyone in the family receive any disability payments or disability benefits from -

1. Social Security Administration? ____
2. Veterans Administration? ____
3. State public welfare or assistance? ____

If "Yes," ask 14b.
b. Was this because of a disability?

1 [] SSA
2 [] VA
3 [] Welfare

If "Yes," ask 14c and d, otherwise continue with list.

c. Who was this? ____
Mark appropriate box in person's column.

d. Anyone else? ____

15a. Does anyone in this family receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?

[] Y
[] N (Household page)

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 15b and c)
[] N

[p. 95]


[MK Note: Page 95 is a response sheet for questions asked on page 60 and page 94. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

SP []
D []

[2-6]
1a.

First name ____
Last name ____
Age ____
Race
1 [] W
2 [] B
3 [] OT

2.

Relationship ____
Sex
1 [] M
2 [] F

3.

Month ____
Date ____
Year ____

C

BED DAYS

[] None (NP)
____ (NP)

DV

[] None (NP)
____ (NP)

HOSP.

[] None (NP)
____ (NP)

Q. No. (Rows 1-5)

Condition (Rows 1-5)

11a.

[] Income

12.

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

13b.

1 [] Workmen's Compensation

14b.

1 [] SSA
2 [] VA
3 [] Welfare

15b.

1 [] AFDC