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[p.66]

[] SP
[] H

1 a. 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


2. 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 ____

L

Ask Condition list _____.
Use Flashcard _____ to determine Sample persons; mark SP boxes.

[MK Note: End section L]

C

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

Bed days
[] None (NP)
____ (NP)
DV
[] None (NP)
____ (NP)
HOSP.
[] None (NP)
____ (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 and 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
2 [] Widowed
3 [] Never married
4 [] Divorced
5 [] Separated
6 [] Married - spouse absent

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).

5 a. 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 more of the day?

Days ____
00 [] None

9 a. 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 the 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.

10 a. 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. 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.]

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. 68]

11 a. 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?

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


12 a. 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. 69]


[MK Note: Page 69 appears to be a response sheet for questions asked on page 68. 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 ____

d.

[] 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. 70]


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)

15 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 (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)

16 a. 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.

17 a. 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)


18 a. 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. 71]


[MK Note: Page 71 appears to be a response sheet for questions asked on page 70. 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. 72]


Ages 17+:
19 a. 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:
20 a. 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)

21 a. 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)

22 a. 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)

23 a. 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)

24 a. 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)

26 a. 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

27 a. 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

________


28 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?
If "old age" only, ask: Is this limitation caused by any specific condition?
Enter condition in item C. Ask 28c

[] Old age only (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. 73]


[MK Note: Page 73 appears to be a response sheet for questions asked on page 72. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

19 and 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. 74]

29 a. 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)

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

[] Y
[] N (NP)

b. Is this hospitalization included in the number you gave me for --?
If "No," correct entries in 29 and item C for mother and/or baby.

[] Y
[] N

[p. 75]


[MK Note: Page 75 contains a response sheet for questions asked on page 74. The response sheet has five columns; only one is represented here since each column contains the same information.]

29a.

[] Y
[] N (Item C)

b.

Times ____ (Item C)

30b.

[] Y

c.

Times ____ (Item C)

31a.

[] Y
[] N (NP)

b.

[] Y
[] N

[p. 76]

1

32 a. During the past 12 months, did anyone in the family (you, your --, etc.) have -
If "Yes," ask 32b and c.

Conditions affecting the digestive system
A. Gallstones? ____
B. Any other gallbladder trouble? ____
C. Cirrhosis of the liver? ____
D. Fatty liver? ____
E. Hepatitis? ____
F. Yellow jaundice? ____
G. Any other liver trouble? ____
H. Diabetes ____
I. Any disease of the pancreas? ____
J. Ulcer? ____
K. Hernia or rupture? ____
L. A disease of the esophagus? ____
M. Gastritis? ____
N. Frequent indigestion? ____
O. Any other stomach trouble? ____
P. Enteritis? ____

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 [condition affecting the digestive system] ?

____

Make no entry in item C for cold, flu, or grippe even if reported in question 32.

2

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

A. Permanent stiffness or any deformity of the foot, leg, fingers, arm or back? (Permanent stiffness - joints will not move at all) ____
B. Paralysis of any kind? ____

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 affecting the joints]?

____

32 d. During the past 12 months, did anyone in the family (you, your --, etc.) have -
If "Yes," ask 32e and f.

Conditions C-N and V are conditions affecting the bone and muscle
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? ____

e. Who was this?

____

Enter name of condition and letter of line where reported in appropriate person's column in item C.

f. During the past 12 months, did anyone else have [conditions affecting the bone and muscle] ?

____

3

32 a. During the pasat 12 months, did anyone in the family (you, your --, etc.) have -
If "Yes," ask 32b and c.

Glandular disorders
A. Goiter or other thyroid trouble? ____
B. Diabetes? ____
C. Cystic fibrosis? ____
Blood disorder
D. Anemia? ____
Conditions affecting the nervous system
E. Epilepsy? ____
F. Multiple sclerosis? ____
G. Migraine? ____

b. Who was 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 affecting glandular disorders, blood disorders, or conditions affecting the nervous systems]?

____

[p. 77]

1

32 a. During the past 12 months, did anyone in the family have -
If "Yes," ask 32b and c.

Conditions affecting the digestive system
Q. Diverticulitis? ____
R. Colitis? ____
S. Spastic colon? ____
T. Frequent constipation? ____
U. Any other bowel trouble? ____
V. Any other intestinal trouble? ____
W. Cancer of the stomach, colon, or rectum? ____
X. During the past 12 months, did anyone in the family have any other condition of the digestive system. ____
If "Yes," ask: Who was this? -What was the condition? (Enter in item C)

Make no entry in item C for cold, flu, or grippe even if reported in question 32.

b. Who was this? Enter in item C.

____

c. During the past 12 months, did anyone else have [conditions affecting the digestive systems]?

____
2

32 d. During the past 12 months, did anyone in the family have -
If "Yes," ask 32e and f.

Condition O-U and W-Z are conditions affecting 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? ____

e. Who was this? Enter in item C.

____

f. During the past 12 months, did anyone else have [ condition affecting the skin] ?

____

3

32 a. During the past 12 months, did anyone in the family have -
If "Yes," ask 32 b and c.

Conditions affecting the nervous system
H. Neuralgia or neuritis? ____
I. Sciatica? ____
Genito-urinary conditions
J. Nephritis? ____
K. Kidney stones? ____
L. Any other kidney trouble? ____
M. Bladder trouble? ____
N. Prostate trouble? ____
O. Disease of the uterus or ovary? ____
P. Any other female trouble? ____

b. Who was this? Enter in item C.

____

c. During the past 12 months, did anyone else have [conditions affecting the nervous system/ genito-urinary conditions]?

____

[p. 78]

4

32 a. Does anyone in the family (you, your --, etc.) now have -
If "Yes," ask 32b and c.

A-L are conditions affecting hearing/vision/speech
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? ____

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 [condition affecting the hearing/vision/speech] ?

____

5

32 a. Has anyone in the family (you, your --, etc.) ever had -
If "Yes," ask 32b and c.

Conditions affecting the heart and circulatory system
A. Rheumatic fever? ____
B. Rheumatic heart disease? ____
C. Hardening of the arteries or arteriosclerosis? ____
D. Congenital heart disease? ____
E. Coronary heart disease? ____
F. High blood pressure? ____
G. Stroke or a cerebrovascular accident? ____
H. Hemorrhage of the brain? ____
I. Angina pectoris? ____
J. Myocardial infarction? ____
K. Any other heart attack? ____

b. Who was this? -Enter name of condition and letter of line where reported in appropriate person's column in item C.

____

c. Has anyone else ever had [conditions affecting the heart and circulatory system]?

____

6

32 a. During the past 12 months, did anyone in the family (you, your --, etc.) have -
If "Yes," ask 32b and c.

Conditions affecting the respiratory system
A. Bronchitis? ____
B. Bronchiectasis? (brong-ke-ek-tah-sis) ____
C. Asthma? ____
D. Hay fever? ____
E. Nasal polyp? ____
F. Sinus trouble? ____
G. Deflected or deviated nasal septum? ____
H. *Tonsillitis or enlargement of the tonsils or adenoids? ____
I. *Laryngitis? ____

* If reported in question 32 only ask:

1. How many times did -- have [condition] in the past 12 months? ____
If 2+ enter in item C.
If only 1 time, ask:
2. How long did it last? ____
If 1 month or longer, enter in item C.
If less than 1 month, do not record.
If tonsils or adenoids removed during the past 12 months, enter condition causing removal in item C.

b. Who was 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 affecting the respiratory system]?

____

Make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 32.

[p. 79]

4

32 a. Does anyone in the family now have -
If "Yes," ask 32b and c.

Conditions O-W are impairments/ Conditions Y and Z affect the nervous system
O. Palsy or cerebral palsy? ____
P. Paralysis of any kind? ____
Q. Curvature of the spine? ____
R. Repeated trouble with the 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? (Permanent stiffness - joints will not move at all) ____
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? ____

b. Who is this? Enter in item C.

____

c. Does anyone else have [impairments or conditions affecting nervous system] ?

____

5

32 a. During the past 12 months, did anyone in the family (you, your --, etc.) have -
If "Yes," ask 32b and c.

Conditions affecting the heart and circulatory system
L. Damaged heart valves? ____
M. Tachycardia or rapid heart? ____
N. Heart murmur? ____
O. Any other heart trouble? ____
P. Aneurysm? ____
Q. Any blood clots? ____
R. Gangrene? ____
S. Varicose veins? ____
T. Hemorrhoids or piles? ____
U. Phlebitis or thrombophlebitis? ____
V. Any other condition affecting blood circulation? ____

b. Who was this? Enter in item C.

____

c. During the past 12 months did anyone else have [conditions affecting the heart and circulatory system ]?

____

6

32 a. During the past 12 months, did anyone in the family have -
If "Yes," ask 32b and c.

Conditions affecting the respiratory system
J. Tumor, cyst, or growth of the bronchial tube or lung? ____
K. Emphysema? ____
L. Pleurisy? ____
M. Tuberculosis? ____
N. Abscess of the lung? ____
O. Tumor, cyst, or growth of the throat, larynx, or trachea? ____
P. Any work-related respiratory condition such as dust on the lungs, silicosis or pneu-mo-co-ni-o-sis? ____
Q. During the past 12 months did anyone in the family have any other respiratory, lung, or pulmonary condition? ____
If "Yes," ask: Who was this? -What was the condition? (Enter in item C)
____

b. Who was this? Enter in item C.

____

c. During the past 12 months, did anyone else have [condition affecting respiratory system] ?

____

Make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 32.

[p. 80]


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

BD

Mark box(es) for item C.

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

34. 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 +)

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

[p. 81]


[MK Note: Page 81 contains a response sheet for questions asked on page 80. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]

33.

1 [] E
2 [] G
3 [] F
4 [] P
BD
1 [] 1+ Bed Days
2 [] 1+ Hospital Stays
3 [] No Bed Days

34.

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

R

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

[p.112]


Mark box or ask:
1 a. About how tall is -- without shoes?

[] Under 17 (NP)
Feet ____
Inches ____


b. About how much does -- weigh without shoes?

Pounds ____

Mark box or ask:

2 a. What is the highest grade or year -- attended in school?

[] Und. 17 (NP)
00 [] None (3)

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


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

1 [] Y
2 [] N (NP)

b. When did -- 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

Hand Card R - Mark box or ask:

CARD R

1. Aleut, Eskimo or American Indian
2. Asian or Pacific Islander
3. Black
4. White
5. Another group not listed - Specify

4 a. Please give me the number of the group or groups which describes --'s racial background.
Circle all that apply.
1 - Alaskan Native or American Indian
2 - Asian or Pacific Islander
3 - Black
4 - White
5 - Another group not listed - Please specify.

[] Under 17 (NP)
[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

If multiple entries ask:
b. Which of those groups; that is, (entries in 4a) would you say best describes --'s racial background?

[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____


Hand Card O
CARD O

1. Puerto Rican
2. Cuban
3. Mexican
4. Mexicano
5. Mexican-American
6. Chicano
7. Other Latin American
8. Other Spanish

Mark box or ask:
5 a. Are any of those groups -- 's national origin or ancestry? (Where did --'s ancestors come from?)

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

b. Please give me the number of the group.
Circle all that apply.

1 - Puerto Rican
2 - Cuban
3 - Mexican
4 - Mexicano
5 - Mexican-American
6 - Chicano
7 - Other Latin American
8 - Other Spanish
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8

[p. 113]


[MK Note: Page 113 contains a response sheet for questions asked on page 112. The response sheet contains five columns to enter responses in; only one is represented here since each column contains the same information.]

1a.

[] Under 17 (NP)
Feet ____
Inches ____

b

Pounds ____

2a.

[] Und. 17 (NP)
00 [] None (3)

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

3a.

1 [] Y
2 [] N (NP)

b.

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

4a.

[] Under 17 (NP)
[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

b.

[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

5a.

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

b.

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8

[p. 114]

Mark box or ask:


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

[] Under 17 (NP)
1 [] Y (7)
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 (7)

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 6a, b, or c.
If "Yes" in 6c only, questions 7a through 7e apply to this person's last full-time civilian job.
7 a. For whom did -- work? Name of company, business, organization, or other employer

Employer ________

b. What kind of business or industry is this? For example, TV and radio manufacturing, retail shoe store, State Labor Dept., farm

Industry ________

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

Duties ________

Complete from entries in 7a-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 (8)


f. How many hours a week (does/did) -- usually work at that job?

Hours ____

If "N" in 6b, go to 8; otherwise ask:
g. During the past 2 weeks, did -- have any other job or business?

1 [] Y
2 [] N (8)

h. How many hours a week does -- usually work for pay at all jobs?

Hours ____

8. Since (12-month date) a year ago, how many weeks did -- work, either part-time or full-time, not counting work around the house? Include paid sick leave and paid vacation.

00 [] None
52 [] All year - 52 weeks
Weeks ____

If "Y" in 6a, go to NP; otherwise ask:
9. How long has it been since -- last worked at a job or business for two or more weeks, either full-time or part-time?

[] Never worked
[] Less than 1 year
Number of years ____

[p. 115]


[MK Note: Page 115 contains a response sheet for questions asked on page 114. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

6a.

[] Under 17 (NP)
1 [] Y (7)
2 [] N

b.

1 [] Y
2 [] N

c.

1 [] Y
2 [] N (7)

d.

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

7a.

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 (8)

f.

Hours ____

g.

1 [] Y
2 [] N (8)

h.

Hours ____

8.

00 [] None
52 [] All year - 52 weeks
Weeks ____

9.

[] Never worked
[] Less than 1 year
Number of years ____

[p. 116]

10 a. There is a national program called Medicaid which pays for health care for persons in need. (In this State it is also called _____.) During the past 12 months, has anyone in this family received health care which has been or will be paid by Medicaid (or _____)?

[] Y
[] N (11)

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

1 [] Medicaid

c. Anyone else?

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

11 a. Does anyone in the family now have a Medicaid (or ____ ) card which looks like this? Show Medicaid card.

[] Y
[] N (12)

b. Who is this? Mark "Card" box in person's column.

1 [] Card

c. Anyone else?

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

If "Card," ask:
d. May I please see -- 's (and --) card(s)? Mark appropriate box(es) in person's column.

[] Medicaid card seen
1 [] Current
2 [] Expired
3 [] No card seen
8 [] Other card seen (Specify) ____


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

12. 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


13 a. 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 13a and b)
[] N

If only one person with "Income" box marked, go to 15.
If 2 ore more persons with "Income" box marked, ask 14 for each:


14. 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

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

[] Y
[] N (16)

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. 117]


[MK Note: Page 117 is a response sheet for questions asked on page 116. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

10b.

1 [] Medicaid

11b.

1 [] Card

d.

[] Medicaid card seen
1 [] Current
2 [] Expired
3 [] No card seen
8 [] Other card seen (Specify) ____

13a.

[] Income

14.

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

15b.

1 [] AFDC

[p. 118]

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

[] Y
[] N (17)

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

1 [] SSI

c. Anyone else?

[] Y (Reask 17b and c)
[] N

17 a. Does anyone in the family receive any (other) income from Social Security?

[] Y
[] N (19)

b. Who is this? Mark "Social Security" box in person's column.

1 [] Social Security

c. Anyone else?

[] Y (Reask 17b and c)
[] N

People may receive Social Security benefits because of their own work experience or because they are dependents or survivors of someone who qualified, based on work experience.
If "Social Security" ask:

18. Does (person in 17b) receive Social Security payments because of -- 's own work experience or because -- is a dependent or survivor of someone who worked?

1 [] Work experience
2 [] Dependent or survivor

19 a. Including retirement payments received because of disability, does anyone in the family, (that is you, your --, etc.) receive any income from -

(1) Railroad retirement?
[] Y
[] N
(2) Pension as a military retiree?
[] Y
[] N
(3) Government employee pension? (Federal, State, or local government)
[] Y
[] N
(4) Private employer or union pension?
[] Y
[] N

If "Yes," ask 19b and c
b. Who is this? Mark box in person's column.

1 [] Railroad
2 [] Military
3 [] Government employee
4 [] Private or union

c. Anyone else?

____

For each income reported in 19b, ask:
20. Does -- receive the (entry in 19b) because of --'s own work experience or because -- is a dependent or survivor of someone who worked?

RR
OWN ____
SURV ____
Military
OWN ____
SURV ____
Gov't
OWN ____
SURV ____
Private
OWN ____
SURV ____

[p. 119]


[Page 119 contains a response sheet for questions asked on page 66 and page 118. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

(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)

16b.

1 [] SSI

17b.

1 [] Social Security

18.

1 [] Work experience
2 [] Dependent or survivor

19b.

1 [] Railroad
2 [] Military
3 [] Government employee
4 [] Private or union

20.

RR
OWN ____
SURV ____
Military
OWN ____
SURV ____
Gov't
OWN ____
SURV ____
Private
OWN ____
SURV ____