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Appendix III. Questionnaire and Flash Cards
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
U.S. Health Interview Survey
[] Permit
[] Address
[] Cen -- Sup
[] Special place
Segment ____
Serial ____
6a. What is your exact address? (Include House No., Apt. No., or other identification and ZIP code) ____
State ____
ZIP code ____
Listing Sheet
Line No. ____
b. Is this your mailing address? Mark box or specify if different. Include ZIP code. ____
City ____
State ____
ZIP code ____
c. Special place name ____
Type code ____
When was this structure originally built?
[] After 4-1-70 (Go to 9c, complete if required and end interview)
2 [] OTHER unit
[] N
[] N
[] N
GO TO PROBE PAGE 2
1 [] URBAN (13)
-- Special Place units not coded 85-88 in 6c, go to 13.
11. Do you own or rent this place?
[] Rent
[] Rent for free
12a. Does the place you (own/rent/rent for free) have 10 acres or more?
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?
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?
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?
Area code/Number _ _ _ _ _ _ _ _ _ _
16. Was this interview observed?
2 [] N
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
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.
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]
Date ____
Beginning time ____
[] p.m.
[] p.m.
[p. 96]
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
Line number ____
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 other type of Segments,
-Otherwise, go to (3)
3. If listed, enter sheet and line number, STOP Table X, and continue interview for original sample unit.
L ____
If unlisted,
-And another type of Segment, go to (5)
4. If outside Area Segment boundary, mark box below, STOP and -
OR
* Go to Household page, item 9, or Probe page, question 1 (as applicable).
5. Are these (Specify location) quarters for more than one group of people? (If "Yes," fill one line for each group)
[] No
USE OR CHARACTERISTICS
OCCUPIED
6. Do the occupants of these (Specify location) quarters live and eat with any other group of people?
[] No
ALL QUARTERS
Do these quarters in (specify location) have:
7. Direct access from the outside or through a common hall?
[] No
8. Complete kitchen facilities for this unit only?
[] 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.
[] HU
[] OT
NOTE: Be sure to continue interview for original sample unit.