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[p.56]

[] SP
[] H

1a. What is the name of the head of this household? -- Enter name in first column

First name ____
Last name ____
Age ____

Race
[] 1 W
[] 2 B
[] 3 OT

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 -- date of birth? (Enter date and Age and circle Race and Sex.)

Month ____
Date ____
Year ____
Race
[] 1 W
[] 2 B
[] OT
Sex
[] 1 M
[] 2 F

L
Ask Condition list ____. Determine Sample persons; mark SP box.

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 ____


If 17+ ask:
4. Is -- now married, widowed, divorced, separated, or never married?

[] 0 Under 17
[] 1 Married -- spouse present
[] 6 Married -- spouse absent
[] 2 Widowed
[] 4 Divorced
[] 5 Separated
[] 3 Never married

H
If related persons 17 and over are listed in addition to the respondent and are not present, say:

We would like to have all adult family members 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

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).

5a. During those 2 weeks, did -- stay in bed because of any illness or injury?

[] Y (5b)
[] 00 N (If age: 17+ (6) 6-17 (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) 6-17 (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 reported 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 most of the day?

Days ____
[] 00 None

9a. (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 that 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.

10a. 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.

[pg. 57]

[] SP
[] H

[Item C below - questions 1a-10c are repeated 5 times.]

First name ____
Last name ____
Age ____

Race
1 [] W
2 [] B
3 [] OT
Relationship ________

Sex
1 [] M
2 [] F
Month ____
Date ____
Year _ _ _ _
C
Bed Days
[] None (NP)
____ (NP)
DV
[] None (NP)
____ (NP)
Hosp.
[] None (NP)
____ (NP)
Q. No. ____
Condition ____
[] 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
a. [] Y (5b)
[] 00 N (If age: 17+ (6) 6-17 (7) Under 6 (9))

b. Days ____ (If age: 17+ (6) 6-17 (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.

[pg.58]

11a. 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? ____

d. Did anyone have any other accidents or injuries during that period?

[] Y (reask 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


12a. During the past 2 weeks, did anyone in the family go to the 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 a dentist?

No. of dental visits ____ (NP)


Do not ask for children 1yr. 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/age 1 or under

[pg. 59]


14. During those 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? Do not count times while an overnight patient in a hospital.

[] 00 None (NP)
Number of visits ____

(Besides those visits)
15a. During those 2 weeks, 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 (Reask 15b and c)
[] N

If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?

Number of visits ____ (NP)

16a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (17)

b. Who was that phone call about? ____
-- Mark "Phone call" 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.
17a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (Item C THEN 17d)
[] Pregnancy (17a)
[] 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

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)


18a. 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 while 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 weeks-6 months
4[] Over 6-12 months
5[] 1 year
6[] 2-4 years
7[] 5+ years
8[] Never

[p. 60]


Ages 17+
19a. 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?

[The below responses were used for both questions 19 and 20 and may not apply to all of question 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)

b. What was -- doing? ____

If 45+ years and was 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
20a. 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 years (21)
0[] Under 1 (22)

21a. 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)

22a. Is -- limited in any way because of his health?

1[] Y
5[] N (NP)

b. In what way is he limited? Record limitation, not condition.

________ (28)

23a. 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)

24a. 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?

1[] Y
[] N (28)

26a. 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 kinds or amount of other activities because of his health?

3[] Y (28)
[] N

27a. 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.

________


28a. 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. 61]

29a. 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)

30a. 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.

31a. Was -- born in a hospital?
If "Yes," and no hospitalization 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.62]

1

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

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 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 digestive system.

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

2

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

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?

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 . . .?

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?

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

c. Arthritis of any kind or rheumatism?
d. Gout?
e. Lumbago?
f. Osteomyelitis? (os-tee-ah-my-uh-lite-iss)
g. A bone cyst or bone spur?
h. Any other diseases 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 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-ah-my-uh-lite-iss)
g. A bone cyst or bone spur?
h. Any other diseases 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?

3

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

a. Goiter or other thyroid trouble? (Glandular disorders)
b. Diabetes? (Glandular disorders)
c. Cystic fibrosis? (Glandular disorders)
d. Anemia Blood disorder (Blood disorder)
e. Epilepsy? (Condition affecting the nervous system)
f. Multiple sclerosis? (Condition affecting the nervous system)
g. Migraine? (Condition affecting the nervous system)

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 . . .?

a. Goiter or other thyroid trouble? (Glandular disorders)
b. Diabetes? (Glandular disorders)
c. Cystic fibrosis? (Glandular disorders)
d. Anemia Blood disorder (Blood disorder)
e. Epilepsy? (Condition affecting the nervous system)
f. Multiple sclerosis? (Condition affecting the nervous system)
g. Migraine? (Condition affecting the nervous system)

[p. 63]

1

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

q. Diverticulitis?
r. Colitis?
s. A spastic colon?
t. FREQUENT constipation?
u. Any other bowel trouble?
v. Any other intestinal trouble?
w. Cancer of the stomach, intestines, 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)

b. Who was this? Enter in item C.

c. During the past 12 months, did anyone else have . . .?

Conditions affecting the digestive system.

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

If "Yes," ask: Who was this? -- What was the condition? (Enter in item C)

2

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

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. Any 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 . . .?

Conditions O-U and W-Z are conditions affecting the skin.

3

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

h. Neuralgia or neuritis?
i. Sciatica?
j. Nephritis?
k. Kidney stones?
l. Any other kidney trouble?
m. Bladder trouble?
n. Prostate trouble?
o. Any 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 H and I are conditions affecting the skin; conditions L and M are genito-urinary conditions.

[p. 64]

4

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

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 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 . . .?

A-L are conditions affecting hearing, vision, and/or speech

5

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

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. A stroke or 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

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

a. Bronchitis?
b. Bronchiectosis? (brong-ke-ek tah-sis)
c. Asthma?
d. Hay fever?
e. A nasal polyp?
f. Sinus trouble?
g. A deflected or deviated nasal septum?
h. *Tonsillitis or enlargement of the tonsils or adenoids?
i. *Laryngitis?

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]?

* If reported in question 32 only, ask:
1. How many times did -- have [condition] in the past 12 months? If 2+ times, enter in item C.

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

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

[p. 65]

4

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

o. Palsy or Cerebral Palsy?
p. Paralysis of any kind?
q. Curvature of the spine?
r. Repeated trouble with 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 cause 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 . . ?
Conditions O-W are impairments. Conditions Y and Z affect the nervous system.

5

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

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

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

j. Tumor, cyst, or growth of the bronchial tube or lung?
k. Emphysema?
l. Pleurisy?
m. Tuberculosis?
n. An abscess of the lung?
o. A tumor, cyst, or growth of the throat, larynx, or trachea?
p. Any other work-related respiratory condition, such as dust on the lungs, silicosis, asbestosis, or pneu-mo-co-ni-o-sis?
q. During the past 12 months did anyone (else) 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 . . .?
Make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 32.

Conditions affecting the respiratory system.

[p.66]


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) from item C.

BD
1[] 1+ Bed Days
2[] 1+ Hospital Days
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?)

34. 0[] None
1[] 1-7
2[] 8-30
3[] 31-180 (1-6 months)
4[] 181+ (6 months +)


R

Questions 4-34.
For persons 17 years or over, show who responded (or was present during asking Q's 4-34 of)

If persons responded for self, show whether entirely or partly. For persons under 17, show who responded for them.

R
1[] Responded for self-entirely
2[] Responded for self-partly

Person ____ was respondent

[p. 77]


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

[] Under 17 (NP)
_ _ Feet
_ _ Inches


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

____ Pounds

Mark box or ask:

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

[] Under 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


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

[] 1 Y
[] 2 N (NP)
[] 9 DK (NP)

b. When did -- serve?

Vietnam Era (Aug. '64 - 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

Circle code in descending order of priority. Thus, Other Service (all other periods).......OS
if person served in Vietnam and in Korea, circle VN.

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

c. Was -- ever an active member of a National Guard or military reserve unit?

[] 1 Y
[] 2 N (NP)
[] 3 DK (NP)

d. Was all of --'s active duty service related to National Guard or military reserve training?

[] 1 Y
[] 2 N
[] 9 DK

Hand Card R - Mark box or ask:

CARD R

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

4a. Please give me the number of the group or groups which describes --'s racial background.

Circle all that apply.
1 - Aleut, Eskimo 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 these groups, that is, (entries in 4a) would you say best describes --'s racial background?

[] 1
[] 2
[] 3
[] 4
[] 5 -- Specify ____


Hand Card O - Mark box or ask:
CARD O

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

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

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

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 Latina American
[] 8 Other Spanish

[p. 78]

Mark box or ask:

6a. 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 past 2 weeks, does -- have a job or business?

[] 1 Y
[] 2 N

c. Was -- 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

Mark for all persons.

If "N" in 6a, and 6b, then Question 7 applies to person's LAST job either full-time or part-time. Include military jobs.
7a. For whom did -- (last) work? Name of company, business, organization or other employer

[] Never worked (NP)
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 -- most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishing 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 farm, is the business incorporated?
Yes -- I
No (Or farm) -- SE

working WITHOUT pay in family business or farm? -- WP

Class of worker
[] 1 P
[] 2 F
[] 3 S
[] 4 L
[] 5 I
[] 6 SE
[] 7 WP

W1
Mark appropriate box.

1 [] Under 17 or Nev. W (NP)
2 [] Callback required (NP)
3 [] Person is available

(Earlier 1 was told that you (last) worked as a (occupation in 7c) for (employer in 7a.)
8a. How long (did/have) you ever work(ed) as (occupation in 7c) for (employer in 7a)?

2 [] Weeks
3 [] Months
4 [] Years
Number [of time listed above] ____

b. Have you ever had a job, that is, a specific kind of work for one employer, at which you worked for more than (time in 8a)? Include military jobs.

[] 1 Y
[] 2 N (NP)

Of all the jobs you have ever had, including military jobs, I'd like to know about the one at which you worked longest.

9a. For whom did you work? Name of company, business, organization, or other employer

Employer ____

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

Industry ____

c. What kind of work were you doing? For example, electrical engineer, stock clerk, typist, farmer

Occupation ____

d. What were your most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishes concrete

Duties ____

Complete from entries in 9a-d; if not clear, ask:
e. Were you 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 farm, is the business incorporated?
Yes -- I
No (Or farm) -- SE

working WITHOUT pay in family business or farm? -- WP

Class of worker
[] 1 P
[] 2 F
[] 3 S
[] 4 L
[] 5 I
[] 6 SE
[] 7 WP

f. How long (did/have) you ever work(ed) as a (occupation in 9c) for (employer in 9a)?

[] Less than 1 year
Years ____

[p. 79]

10a. 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 for 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

11a. 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 those 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


13a. 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 or more persons with "Income" box mark, ask 14 for each.

14. Which of those 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. Does anyone in the family received 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 person's column.

1[] AFDC

c. Are any other family members included in this program?

[] Y (Reask 15b and c)
[] N

[p. 80]

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

[] Y
[] N (17)

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

1[] SSI

c. Anyone else?

[] Y (reask 16b and c)
[] N

17a. 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.
Ask for each person with "Social Security" marked in 17b:
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

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

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

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