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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.



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[p.55]

Appendix III. Questionnaire and Flash Cards

U.S. Department of Commerce
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service

U.S. Health Interview Survey

1. Book ____ of ____ books

2. R.O. number

3. Sample

4. Segment type

[] Area
[] Permit
[] Address
[] Cen--Sup
[] Special Place

5. Control number

PSU ____
Segment ____
Serial ____

Listing sheet

Sheet ____
Line No. ____

6a. What is your exact address? (Including House No., Apt. No., or other identification and ZIP code) ____

City ____
State ____
ZIP Code _ _ _ _ _
County ____

b. Is this your mailing address? (Mark box or specify if different; include ZIP code) ____

[ ] Same as 6a

City ____
State ____
ZIP Code _ _ _ _ _
County ____

c. Special place name

Sample unit number ____
Type code ____

7. Year Built

[] Ask
[] Do Not ask

When was this structure originally built?
[] Before 4--1--70 (Continue interview)
[] After 4--1--70 (Go to 9c, complete if required and end interview)


8. Type of living quarters

[] Housing unit
[] Other unit

9. Area segments Only

[] a. Are there any occupied or vacant living quarters besides your own in this building?
[] Y (Fill Table X)
[] N
[] b. Are there any occupied or vacant living quarters besides your own on this floor?
[] Y (Fill Table X)
[] N
[] c. Is there any other building on this property for people to live in - either occupied or vacant?
[] Y (Fill Table X)
[] N
[] d. None

Go to probe page 2


10. Land Use

[] 2 Rural
[] 1 Urban (13)

-- Reg. 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?

[] Own
[] Rent
[] Rent for free

12a. Does the place you (own/rent/rent for free) have 10 acres or more?

[] 1 Y (12b)
[] 2 N (12c)

b. During the past 12 months did sales of crops, livestock, and other farm products from this place amount to $50 or more?

[] 1 Y (13)
[] 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?

[] 1 Y
[] 2 N


13. How many rooms are in this [unit]? Count the kitchen but not the bathroom.

Rooms ____

14. How many bedrooms are in this [unit]?
If "None" Describe in footnotes.

Bedrooms ____


15. What is the telephone number here?

[] 2 None
Area code _ _ _
Number _ _ _ _ _ _ _

16. Was this interview observed?

[] 1 Y
[] 2 N

17. Interviewer's name

Code ____


18. Noninterview reason

Type A

[] 1 Refusal -- Describe in a footnote
[] 2 No one at home, repeated calls (Fill items 1-6a, 7, 8, 10, 12a-c as applicable, 16- 19)
[] 3 Temporarily absent -- Footnote
[] 4 Other (Specify)

Type B

[] 1 Vacant -- nonseasonal
[] 2 Vacant -- seasonal
[] 3 Usual residence elsewhere (Fill items 1-6a, 7-10, 12a-c as applicable. 16-19)
[] 4 Armed Forces
[] 5 Other (Specify)
Type C

[] 1 Unused line of listing sheet
[] 2 Demolished (Fill items 1-6a. 6c if required, 9c if marked. 16-19.)
[] 3 Outside segment (Send Inter--Comm.)
[] 5 Built after April 1, 1970
[] 6 Other (Specify) ____


19. Record of calls [Options for six call records found in original document - not presented here.]

Month ____
Date ____
Beginning time
____ a.m.
____ p.m.
Ending time
____ a.m.
____ p.m.
Completed Mark (X)

20. List column numbers of preferred respondent(s) requiring callbacks for Child Health Supplement.

[] None
Column Number ____

21. Record of additional contacts

Month ____
Date ____
Beginning time
____ a.m.
____ p.m.
Ending time
____ a.m.
____ p.m.

Respondent Col. No. ____

[p. 81]

E
If this questionnaire is for an EXTRA unit, enter Control Number of original sample unit ____

If in AREA SEGMENT, also enter for FIRST unit listed on property ____

Listing Sheet

Sheet Number ____
Line Number ____
Table X - Living Quarters Determinations at Listed Address

Location of Unit
[options for 3 different locations omitted here. All had same questions]

Where are these quarters located? Enter exact description or location, e.g., basement; 2nd floor, rear ________

After entering description or location:

-- In Area Segment, go to (3)
-- In other type of Segments,
-- If living quarters are not within the same specific sample address (and structure, if Permit Segment) -- STOP TABLE X
-- Otherwise go to (3)

-- If listed, enter sheet and line number, STOP Table X, and continue interview for original sample unit.

S ____
L ____

-- If unlisted

-- And Area Segment, go to (4).
- And another type of Segment, go to (5)

If outside Area Segment boundary, mark box below, STOP and

-- Go to next line of Table X, if additional quarters determined.
OR
-- Go to Household page, item 9, or Probe page, question 1 (as applicable).
[] Outside segment boundary

Are these (Specify location) quarters for more than one group of people?

If "Yes," Fill one line for each group

[] Yes
[] No

Use or Characteristics

Occupied
Do the occupants of these (Specify location) quarters live and eat with any group of people?

If "Yes," fill one line for each group.
[] Yes -- Go to (9) and circle N
[] No

All Quarters
Do these quarters in (specify location) have:

Direct access from outside or through a common hall?
[] Yes
[] No

Complete kitchen the facilities for this unit only?
[] Yes
[] No

Classification

N
Not a separate unit. Add occupants to this questionnaire.

(Complete a separate questionnaire for each unrelated person or family group.)

[] N
HU
Separate unit - interview on a separate questionnaire

[] HU
OT
Separate unit -- interview on a separate questionnaire

[] OT

Note: Be sure to continue interview for original sample unit.