[p.141]
Appendix III. Questionnaire and Flash Cards
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
National Health Interview Survey
[] Permit
[] Address
[] Cen-Sup
[] Special Place
Segment
Serial
6a. What is your exact address? (Including House No., Apt. No., or other identification; county and ZIP code)
City ____
State ____
County ____
Zip Code _ _ _ _
Listing Sheet
____ Line No.
b. Is this your mailing address? (Mark box or specify if different; include county and ZIP code)
________
City ____
State ____
County ____
Zip Code _ _ _ _
c. Special place name
Type code
Area segments only
[] Do not ask
When was this structure originally built?
[] After 4-1-70 (Complete item 8c when required; end interview)
[] Do not ask
a. [] Are there any occupied or vacant living quarters besides your own in this building?
[] No
b. [] Are there any occupied or vacant living quarters besides your own on this floor?
[] No
c. [] Is there any other building on this property for people to live in, either occupied or vacant?
[] No
2[] Rural
- SP. PL. units not coded 85-88 in 6c -- Mark "No" in item 9b without asking
b. During the past 12 months, did sales of crops, livestock, and other farm products from this place amount to $1,000 or more?
2[] No (10)
10. Classification of living quarters- Mark by observation
1[] In a Special Place -- Refer to Table D in Part C of manual; then complete 10d or e
2[] NOT in a Special Place (10b)
2[] Through another unit (10c)
[] Also used by another household [Not a separate HU; combine with unit through which access is gained. (Apply merged unit procedure if additional living quarters space was listed separately)]
[] None [Not a separate HU; combine with unit through which access is gained. (Apply merged unit procedure if additional living quarters space was listed separately)]
02[] HU in nontransient hotel, motel etc.
03[] HU- permanent in transient hotel, motel etc.
04[] HU in rooming house
05[] Mobile home or trailer with no permanent room added
06[] Mobile home or trailer with one or more permanent rooms added
07[] HU not specified above- Describe in footnotes
09[] Unit not permanent in transient hotel, motel etc.
10[] Unoccupied tent site or trailer site
11[] Other unit not specified above- Describe in footnotes
Go to Household composition page
11. What is the telephone number here?
____ Area code/number
12. Was this interview observed?
2[] No
02 [] No one at home, repeated calls [Fill items 1-6a,7, 9 as applicable, 10, 12-15]
03 [] Temporarily absent -- Footnote [Fill items 1-6a,7, 9 as applicable, 10, 12-15]
04 [] Other (Specify) ____ [Fill items 1-6a,7, 9 as applicable, 10, 12-15]
06[] Vacant -- seasonal [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
07[] Occupied entirely by persons with URE [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
08[] Occupied entirely by Armed Forces members [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
09[] Unfit or to be demolished [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
10[] Under construction, not ready [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
11[] Converted to temporary business or storage [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
12[] Unoccupied tent site or trailer site [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
13[] Permit granted, construction not started [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
14[] Other (Specify) ____ [Fill items 1-6a,7, 8, 9 as applicable, 10, 12-15]
16[] Demolished [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
17[] House or trailer moved [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
18[] Outside segment [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
19[] Converted to permanent business or storage. [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
20[] Merged [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
21[] Condemned [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
22[] Built after April 1, 1970 [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
23[] Other (Specify) ____ [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
____ Date
____ p.m
____ p.m
16. List column numbers of persons requiring callbacks for "Preventive Care" questions.
Column number
17. Record of additional contacts
____ Date
____ p.m
____ p.m
[p.163]
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
Line Number ____
[In Survey, option for three different addresses; here, only one option is presented, there other two option are identical]
Address of additional living quarters
1. Enter basic address and unit address, if any or description of location
________
________
Location of unit
2Is this a unit in a special place?
[] No
Separateness and Facilities
3. Do the occupants (or intended occupants) or (address in col.1) live and eat separately from all other persons on the property?
[] No- Skip to col (b) and mark N
4. Does (address in col (1)) have direct access from the outside or through a common hall?
[] No
5. Does (address in col (1)) have complete kitchen facilities for that unit only?
[] No- Mark N in Col (6)
Classification
HU. Separate unit-Do not include on this questionnaire. Complete the appropriate segment type column for interviewing instructions
OT. Separate unit-Do not include on this questionnaire. Complete the appropriate segment type column for interviewing instructions
[] HU - Fill col (7), (8), or (9) as appropriate
[] OT- Fill col (7), (8) or (9) as appropriate
Area segments
7. Is this unit - Unlisted and withine the segment boundaries?
[] No- Do not interview
Address, Cen-Sup and Special Place segments
8. Is this unit - unlisted and within the specific address (basic plus unit, if any) of the original sample unit?
[] No- Do not interview
Permit Segments
Is is this unit- unlisted and within the specific address (basic plus unit, if any) of the original sample unit, and within the same structure as the original sample unit?
[] No- Do not interview
NOTE: Be sure to continue interview for original unit after completing Table X for all lines