[p.65]
Appendix III. Questionnaire and Flash Cards
Social and Economic Statistics Administration
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 ____
Listing Sheet
Line No. ____
6a. What is your exact address? (Include House No., Apt. No., or other identification and ZIP code)
State ____
ZIP code ____
County ____
b. Is this your mailing address? Mark box or specify if different. Include ZIP code.
City ____
State ____
ZIP code ____
County ____
c. Special place name
Type code ____
[] Do not Ask
When was this structure originally built?
[] After 4-1-70 (Go to 9c, complete if required and end interview)
2 [] Other unit
[] N
[] N
vacant?
[] N
Go to probe page 2
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?
[] Rent
[] Rent for free
12 a. 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 -- ? Count the kitchen but not the bathroom
14. How many bedrooms are in this -- ? 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 [Fill items 1-6a, 7, 8, 10, 12a-c as applicable, 16-19]
3[] Temporarily absent - Footnote [Fill items 1-6a, 7, 8, 10, 12a-c as applicable, 16-19]
4[] Other (Specify) ____ [Fill items 1-6a, 7, 8, 10, 12a-c as applicable, 16-19]
2[] Vacant -- seasonal [Fill items 1-6a, 7-10, 12a-c as applicable, 16-19]
3[] Usual residence elsewhere [Fill items 1-6a, 7-10, 12a-c as applicable, 16-19]
4[] Armed Forces [Fill items 1-6a, 7-10, 12a-c as applicable, 16-19]
5[] Other (Specify) ____ [Fill items 1-6a, 7-10, 12a-c as applicable, 16-19]
2[] Demolished [Fill items 1-6a, 6c if required, 9c if marked, 16-19. Send Inter-Comm]
3[] Merged [Fill items 1-6a, 6c if required, 9c if marked, 16-19. Send Inter-Comm]
4[] Outside segment [Fill items 1-6a, 6c if required, 9c if marked, 16-19. Send Inter-Comm]
5[] Built after April 1, 1970 [Fill items 1-6a, 6c if required, 9c if marked, 16-19. Send Inter-Comm]
6[] Other (Specify) ____ [Fill items 1-6a, 6c if required, 9c if marked, 16-19. Send Inter-Comm]
19. Record of calls [Options for six call records in original document -- not presented here.]
Date ____
p.m ____.
p.m ____
20. List column numbers of sample persons not interviewed during initial interview
[] N
[] N
(Rows 1-3)
21. Record of additional contacts[Options for four call records in original document -- not presented here]
Date ____
p.m. ____
p.m. ____
[] SS
[] EC
Before leaving household, check that item 20 has an entry. Determine the best time for callbacks.
[p. 120]
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
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.
Please give my household's identifiable information to the National Center for Health Statistics so that my answers can be counted in the survey.
Signature
________
________
________
Date
________