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
 Special Place
Line No. ____
ZIP Code _ _ _ _ _
b. Is this your mailing address? (Mark box or specify if different; include ZIP code) ____
ZIP Code _ _ _ _ _
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)
 Other unit
Go to probe page 2
 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?
 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 from 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
Area code _ _ _
Number _ _ _ _ _ _ _
 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
 4 Other (Specify)
 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)
 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) ____
Column Number ____
Respondent Col. No. ____
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 ____
Line Number ____
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)
-- If listed, enter sheet and line number, STOP Table X, and continue interview for original sample unit.
-- If unlisted
- And another type of Segment, go to (5)
If outside Area Segment boundary, mark box below, STOP and
-- Go to Household page, item 9, or Probe page, question 1 (as applicable).
Are these (Specify location) quarters for more than one group of people?
If "Yes," Fill one line for each group
Use or Characteristics
If "Yes," fill one line for each group.
 Yes -- Go to (9) and circle N
Not a separate unit. Add occupants to this questionnaire.
(Complete a separate questionnaire for each unrelated person or family group.)
Separate unit - interview on a separate questionnaire
Separate unit -- interview on a separate questionnaire
Note: Be sure to continue interview for original sample unit.