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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
[] Permit
[] Address
[] Cen--Sup
[] Special Place
Segment ____
Serial ____
Listing sheet
Line No. ____
6a. What is your exact address? (Including 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)
[] Other unit
[] N
[] N
[] N
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
[] 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
13. How many rooms are in this [unit]? Count the kitchen but not the bathroom.
14. How many bedrooms are in this [unit]?
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
[] 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) ____
19. Record of calls [Options for six call records found in original document - not presented here.]
Date ____
____ p.m.
____ p.m.
20. List column numbers of preferred respondent(s) requiring callbacks for Child Health Supplement.
Column Number ____
21. Record of additional contacts
Date ____
____ p.m.
____ p.m.
Respondent Col. No. ____
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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
Line Number ____
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 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.
L ____
-- If unlisted
- And another type of Segment, go to (5)
If outside Area Segment boundary, mark box below, STOP and
OR
-- 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
[] 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:
[] No
[] No
Classification
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.