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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.



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[p.141]


Appendix III. Questionnaire and Flash Cards

1982 Questionnaire
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

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

____ Sheet No.
____ Line No.

b. Is this your mailing address? (Mark box or specify if different; include county and ZIP code)

[] Same as 6a
________
City ____
State ____
County ____
Zip Code _ _ _ _

c. Special place name

Sample unit number
Type code

Area segments only

7. Year built

[] Ask
[] Do not ask

When was this structure originally built?

[] Before 4-1-70 (Continue interview)
[] After 4-1-70 (Complete item 8c when required; end interview)

8. Coverage Questions

[] Ask items that are marked
[] Do not ask

a. [] Are there any occupied or vacant living quarters besides your own in this building?

[] Yes (Fill Table X)
[] No

b. [] Are there any occupied or vacant living quarters besides your own on this floor?

[] Yes (Fill Table X)
[] No

c. [] Is there any other building on this property for people to live in, either occupied or vacant?

[] Yes (Fill Table X)
[] No


9a. Land Use

1[] Urban (10)

2[] Rural
- Reg. units and SP. PL. units coded 85-88 in 6c - Ask item 9b
- 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?

1[] Yes (10)
2[] No (10)


10. Classification of living quarters- Mark by observation

a. Location of unit
Unit is:
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)
b. Access
1[] Direct (10d)
2[] Through another unit (10c)
c. Complete kitchen facilities
[] For this unit only (10d)
[] 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)]


d. Housing unit (Mark one, then page 2)
01[] House, apartment, flat
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


e. Other unit (Mark one)
08[] Quarters not HU in rooming or boarding house
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?

0[] None
____ Area code/number

12. Was this interview observed?

1[] Yes
2[] No

13. Interviewer's name

____Code


14. Noninterview reason

Type A
01 [] Refusal -- Describe in footnotes [Fill items 1-6a,7, 9 as applicable, 10, 12-15]
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]


Type B
05[] Vacant -- nonseasonal [Fill items 1-6a,7, 8, 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]

Type C
15[] Unused line of listing sheet [Fill items 1-6a, 8c. If marked, 12-15, sent Inter-Comm]
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]


15. Record of calls

____ Month
____ Date
Beginning time
____ a.m
____ p.m
Ending time
____ a.m
____ p.m
Completed Mark (X)

16. List column numbers of persons requiring callbacks for "Preventive Care" questions.

[] None
Column number

17. Record of additional contacts

____ Month
____ Date
Beginning time
____ a.m
____ p.m
Ending time
____ a.m
____ p.m
Completed Col No

[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

Listing sheet
Sheet Number ____
Line Number ____
TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS

[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?

[] Yes- skip to col. b and mark according to Table D in Part C of manual
[] 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?

[] Yes
[] 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?

[] Yes- Skip to col (6) and mark HU
[] No

5. Does (address in col (1)) have complete kitchen facilities for that unit only?

[] Yes- Mark HU in Col (6)
[] No- Mark N in Col (6)

Classification

N. Not a separate unit- Include on this questionnaire
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
6.

[] N- Stopn Table X
[] 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?

[] Yes- interview as an Extra unit
[] 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?

[] Yes- interview as an Extra 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?

[] Yes -interview as on Extra unit
[] No- Do not interview

NOTE: Be sure to continue interview for original unit after completing Table X for all lines