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[p. 108]

EYE CARE PAGE

Complete for each SP
(19+: Self; 17-18: Self or parent; Under 17: Parent)

1. Person number

____

E1
Refer to Flashcard Booklet

1 [] Callback required (Next SP)
2 [] Eligible resp. available

When people need help or advice about their eyes they go to their regular doctor or someone else who takes care of the eyes. Eye care includes examinations, treatments, and surgery. It also includes fitting or adjusting of contact lenses. Eye care does NOT include visits which were only for adjusting frames.

2. Since (12-month date) a year ago, has -- visited a doctor, eye specialist, or someone else for any type of eye care? Please count times a doctor examined --'s eyes even if the visit was not made only for this purpose.

1 [] Y
2 [] N (E3)


3. How many total times since (12-month date) a year ago, has -- visited someone for eye care?

Number ____


4. How many times did -- visit someone for eye care since the first of (hospital probe month) 1979?

0 [] None (E3)
Number ____

5 a. On what date did -- visit someone for eye care (the last time)?

Month ____
Date ____

OR

7777 [] Last week
8888 [] Week before


b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Optical store
[] Other - Specify ____

c. What is the (name and) address of this (place in 5b)?

Name ____
Street ____
City ____
State ____




d. Who did -- see at the (place in 5b) on that visit?

Name ____
Spec. code ____

e. Is (person in 5d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?

1 [] Ophthalmologist (E3)
2 [] Optometrist (E3)
3 [] Optician (E3)
[] Other - Specify ____


f. Is this person a medical doctor?

1 [] Y
2 [] N
9 [] DK


E2

[] 2+ visits in 4
[] Other (E3)

6 a. On what date did -- visit someone for eye care the time before last?

Month ____
Date ____
OR
7777 [] Last week
8888 [] Week before


b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Optical store
[] Other - Specify ____

c. What is the (name and) address of this (place in 6b)?

Name ____
Street ____
City ____
State ____


d. Who did -- see at the (place in 6b) on that visit?

Name ____
Spec. code ____

e. Is (person in 6d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?

1 [] Ophthalmologist (E2)
2 [] Optometrist (E2)
3 [] Optician (E2)
[] Other - Specify ____


f. Is this person a medical doctor?

1 [] Y
2 [] N
9 [] DK

E3
a. Mark first appropriate box

1 [] Under 17
2 [] Present for all questions
3 [] Present for 1+ questions
4 [] Not present

b. Enter person number(s) of person who responded

Person No. of respondent(s) ____
SPECIALTY CODES
1 - Ophthalmologist
2 - Optometrist
3 - Optician
4 - M.D. - not ophthalmologist
5 - M.D. - DK type
6 - Not an M.D.
7 - DK if M.D.
E4
1 [] Complete - Personal visit
2 [] Complete - telephone
3 [] Refused
8 [] Other - Specify ____

[p. 109]


[MK Note: Page 109 appears to be a duplicate of page 108.]

EYE CARE PAGE

Complete for each SP
(19+: Self; 17-18: Self or parent; Under 17: Parent)

1. Person number

____

E1
Refer to Flashcard Booklet

1 [] Callback required (Next SP)
2 [] Eligible resp. available

When people need help or advice about their eyes they go to their regular doctor or someone else who takes care of the eyes. Eye care includes examinations, treatments, and surgery. It also includes fitting or adjusting of contact lenses. Eye care does NOT include visits which were only for adjusting frames.

2. Since (12-month date) a year ago, has -- visited a doctor, eye specialist, or someone else for any type of eye care? Please count times a doctor examined --'s eyes even if the visit was not made only for this purpose.

1 [] Y
2 [] N (E3)

3. How many total times since (12-month date) a year ago, has -- visited someone for eye care?

Number ____


4. How many times did -- visit someone for eye care since the first of (hospital probe month) 1979?

0 [] None (E3)
Number ____

5 a. On what date did --visit someone for eye care (the last time)?

Month ____
Date ____
OR
7777 [] Last week
8888 [] Week before

b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Optical store
[] Other - Specify ____

c. What is the (name and) address of this (place in 5b)?

Name ____
Street ____
City ____
State ____


d. Who did -- see at the (place in 5b) on that visit?

Name ____
Spec. code ____

e. Is (person in 5d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?

1 [] Ophthalmologist (E3)
2 [] Optometrist (E3)
3 [] Optician (E3)
[] Other - Specify ____

f. Is this person a medical doctor?

1 [] Y
2 [] N
9 [] DK

E2

[] 2+ visits in 4
[] Other (E3)
6 a. On what date did -- visit someone for eye care the time before last?

Month ____
Date ____
OR
7777 [] Last week
8888 [] Week before

b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Optical store
[] Other - Specify ____

c. What is the (name and) address of this (place in 6b)?

Name ____
Street ____
City ____
State ____

d. Who did -- see at the (place in 6b) on that visit?

Name ____
Spec. code ____

e. Is (person in 6d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?

1 [] Ophthalmologist (E2)
2 [] Optometrist (E2)
3 [] Optician (E2)
[] Other - Specify ____

f. Is this person a medical doctor?

1 [] Y
2 [] N
9 [] DK

E3
a. Mark first appropriate box

1 [] Under 17
2 [] Present for all questions
3 [] Present for 1+ questions
4 [] Not present

b. Enter person number(s) of person who responded

Person No. of respondent(s) ____
SPECIALTY CODES
1 - Ophthalmologist
2 - Optometrist
3 - Optician
4 - M.D. - not ophthalmologist
5 - M.D. - DK type
6 - Not an M.D.
7 - DK if M.D.
E4
1 [] Complete - Personal visit
2 [] Complete - telephone
3 [] Refused
8 [] Other - Specify ____