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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

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


TYPE B
1[] Vacant -- nonseasonal [Fill items 1-6a,6c if required,9c if marked, 16-19.Send Inter-Comm]
2[] Vacant -- seasonal [Fill items 1-6a,6c if required,9c if marked, 16-19.Send Inter-Comm]
3[] Usual residence elsewhere [Fill items 1-6a,6c if required,9c if marked, 16-19.Send Inter-Comm]
4[] Armed Forces [Fill items 1-6a,6c if required,9c if marked, 16-19.Send Inter-Comm]
5[] Other (Specify) ____ [Fill items 1-6a,6c if required,9c if marked, 16-19.Send Inter-Comm]
TYPE C
1[] Unused line of listing sheet [Fill Items 1-6a,6c if required,9c if marked, 16-19. Send Inter-Comm]
2[] Demolished [Fill Items 1-6a,6c if required,9c if marked, 16-19. Send Inter-Comm]
3[] Outside segment [Fill Items 1-6a,6c if required,9c if marked, 16-19. Send Inter-Comm]
5[] Built after April 1, 1970 [Fill Items 1-6a,6c if required,9c if marked, 16-19. Send Inter-Comm]
6[] Other (Specify) ____ [Fill Items 1-6a,6c if required,9c if marked, 16-19. Send Inter-Comm]


19. Record of calls [Options for six call records 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.73]

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

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 far more than one group of people?
If "yes" fill one line for each group.

[] Yes
[] No

Use of characteristics

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

[] Yes (go to (9) and circle no
[] No

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

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

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

Classification

N- Not a separate unit - Add occupants to this questionaire (complete a separate questionaire for each unrelated person or family group)
HU, OT - Separate unit- interview on a separate questionnaire.

[] N
[] NU
[] OT

Note: Be sure to continue interview for original sample unit