p
[p.56]

[] SC
[] SCHOOL

1a. What are the name of all persons living or staying here? - Enter name in first column

b. What are the names of all the other persons living or staying 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?

d. Have I missed anyone who USUALLY lives here but is now away from home?

e. Do any of the people in this household have a home anywhere else?

* 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?

2. What is -- relationship to (Head of household)?

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

L
Ask Condition list ____ . Determine sample child; mark SC box.

C
1. Record the number of Bed Days, Doctor Visits, and Hospitalizations

2. Record each condition in the person's column, with the question number(s) where it was
reported.

If 17+ ask:
4. Is -- now married, widowed, divorced, separated, or 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.

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?

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?

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?

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?

b. Did any other condition cause him to (to stay in bed, miss work, miss school, cut down) during that period?

c. What condition?

Fill item C, (BED DAYS), from 5b for all persons.

[p. 57]

11a. During the past 2 weeks, did anyone in the family, that is you, your --, etc., have any (other) accidents or injuries?

b. Who was this? - Mark "Accident or injury" box in person's column.

c. What was the injury?

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

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?

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

b. Who was this? - Mark "Dental visit" box in person's column.

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

If "Dental visit," ask:
d. During the past 2 weeks, how many times did -- go to a dentist?

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?

[p.58]

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.

(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?

b. Who was this? - Mark "Doctor visit" box in person's column.

c. Anyone else?

If "Doctor visit," ask:

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

b. Who was that phone call about? - Mark "Phone call" in person's column.

c. Any calls about anyone else?

If "Phone call," ask:
d. How many telephone calls were made to get medical advice about --?

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?

b. Did -- see or talk to a doctor about any specific condition?

c. What condition?

d. During that period, did -- see or talk to a doctor about any other condition?

e. During the past 2 weeks was -- sick because of her pregnancy?

f. What was the matter?

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.)

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.

[p.59]

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?

If 'something else" ask:
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?

If "something else," ask:
b. What was -- doing?

Ages under 6

21a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

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

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

23a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work - keep house) at all?

c. Is he limited in the kind of (work-housework) he can do because of his health?

d. Is he limited in the amount of (work-housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kinds or amount of other activities because of his health?

27a. Is -- limited in ANY WAY because of a disability or health?

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?}

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

c. Is this limitation caused by any other condition?

Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?

[p. 60]

29a. Was -- a patient in a hospital at any time since (date) a year ago?

b. How many times was -- in a hospital since (date) a year ago?

30a. Was anyone in the family in a nursing home, convalescent home, or similar place since (date) a year ago?

b. Who was this? - Circle "Y" in person's column.

If "Y," ask:
c. During that period, how many times was -- in a nursing home or similar place?

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.

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.

[p.61-62]

1

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

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 . . .?

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.

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 . . .?

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

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 [condition affectin bone and muscle and skin]?

3

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

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 . . .?

[p.63-64]

4

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

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 . . .?

5

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

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 . . .?

6

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

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 . . .?

* If reported in question 32 only, ask:
1. How many times did -- have -- 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]

33. Compared to other persons --'s age, would you say that his health is excellent, good, fair, or poor?

BD
Mark box(es) from item C.

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?)

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

R
For persons 17 years or over, show who responded for (or was present during the asking of) Questions 4-34.
If persons responded for self, show whether entirely or partly. For persons under 17, show who responded for them.

[p.70]

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

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

Mark box or ask:
2a. What is the highest grade or year -- attended in school?

b. Did -- finish the [his/her] grade (year)?

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

b. When did -- serve?
Circle code in descending order of priority. Thus, if person served in Vietnam and in Korea, circle VN.
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.

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

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

Hand Card R - Mark box or ask:
CARD R

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

If multiple entries ask:
b. Which of these groups, that is, (entries in 4a) would you say BEST describes --'s racial background?

Hand Card O - Mark box or ask:
CARD O

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

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 Latin American
8- Other Spanish

[p.71]

Mark box or ask:

6a. Did -- work at any time last week or the week before - not counting work around the house?

b. Even though -- did not work during these past 2 weeks, does -- have a job or business?

c. Was -- looking for work or on layoff from a job?

d. Which -- looking for work or on layoff from a job?

Ask for all person with a "Yes" in 6a, b or c.
If "Yes" in 6c only, questions 7a through 7e apply to this person's LAST full-time civilian job.


7a. For whom did -- (last) work? Name of company, business, organization or other employer.

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

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

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

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
Was -- a FEDERAL government employee?........F
Was -- a STATE government employee?........S
Was -- a LOCAL government employee?........L
Was -- self-employed in OWN business, professional practice or farm?
If not farm, is the business incorporated?
Yes.......I
No (Or farm)........SE
Was -- working WITHOUT pay in family business or farm?........WP

8a. 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 ____)?

b. Who was this? Mark "Medicaid" box in person's column.

c. Anyone else?

9a. Does anyone in the family now have a Medicaid (or ____ ) card which looks like this? Show Medicaid card.

b. Who is this? Mark "Card" box in person's column.

c. Anyone else?

If "Card," ask:
d. May I please see --'s (and --) card(s)?
Mark appropriate box(es) in person's column.

[p.72]

Hand Card I.
CARD I

10. 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.

11a. Which (other) family members received some income during the past 12 months?
Mark "Income" box in person's column.

b. Did any other family members receive any income during the past 12 months?

If only one person with "Income" box marked, go to 13.

If 2 or more persons with "Income" box mark, ask 12 for each.
12. Which of those income groups represents --'s income for the past 12 months?

13a. Does anyone in this family receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?

b. Which (other) family members are included in the AFDC assistance payment?
Mark "AFDC" box in person's column.

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

14a. Does anyone in the family receive the "Supplemental Security Income" or "SSI" gold-colored check?

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

c. Anyone else?

15a. Does anyone in the family receive any (other) income from Social Security?

b. Who is this? Mark "Social Security" box in person's column.

c. Anyone else?

CH
Mark box.