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[p.142]

[] Old age [] AF

A. Household Composition page

1


1a. What are the names of all persons living or staying here? Start with the name of the person or one of the persons who owns or rents this home. Enter name in REFERENCE PERSON column.

First name ____
Last name ____
Age ____

Sex
1[] M
2[] F

b. What are the names of all the other persons living or staying here? Enter names in columns.

c. I have listed (read names). Have I missed:

Any babies or small children?
If "Yes" enter names in columns
[] Yes
[] No
Any lodgers, boarders, or persons you employ who liver here?
If "Yes" enter names in columns.
[] Yes
[] No
Anyone who Usually lives here but is now away from home traveling or in a hospital?
If "Yes" enter names in column.
[] Yes
[] No
Anyone else staying here?
If "Yes" enter names in columns.
[] Yes
[] No

d. Do all of the persons you have named usually live here?
Probe if necessary:
Does -- usually live somewhere else?

[] Yes (2)
[] No (Apply Household Membership Rules. Delete nonhousehold members by an "X" from 1-C2 and enter reason)

Ask for all persons beginning with column 2:

2. What is -- relationship to (reference person) ?

Relationship ____
Reference Person


3. What is -- date of birth?
(Enter date and age and mark sex.)

Date of birth
Month ____
Date ____
Year ____

C1

Hosp
00[] None
____ Number
Work
1[] Wa
2[] Wb
RD
[] Yes
[] No
2-wk DV
00[] None
____ Number
C2

[Option for five record in original document- not presented here]
LA ____
RA ____
DV ____
INJ ____
CL LTR ____
HS ____
COND ____
Reference Periods
A1
2-week period
12- Month Date
13- Month hospital Date
A2
Ask Condition list ____

A3
Refer to ages of all related HH members

[] All persons 62 and over (5)
[] Other (4)
4a. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States?

[] Yes
[] No (5)

b. Who is this?
Delete column number(s)___________ by an "X" from 1-C2

c. Anyone else?

[] Yes (Reask 4b and c)
[] No

Ask for each person in armed forces:
d. Where does -- usually live and sleep, here or somewhere else?
Mark box in person's column

[] Living at home
[] Not living at home

If related persons 17 and over are listed in addition to the respondent and are not present, say:
5.We would like to have all adult family members who are at home take part in the interview. Are (names of persons 17 and over) at home now? If "Yes," ask: Could they join us? (Allow time)

Read to respondent(s):
This survey is being conducted to collect information on the nation's health. I will ask about hospitalizations, disability, visits to doctors, illness in the family, and other health related items.

HOSPITAL PROBE

6a. Since (13-month hospital date) a year ago, was -- a patient in a hospital overnight?

1[] Yes
2[] No (Mark "HOSP." box, then NP)

b. How many different times did -- stay in any hospital overnight or longer since (13 month hospital date) a year ago?

____ Number of times (Make entry in "HOSP." box then NP)

Ask for each child under one:
7a. Was -- born in a hospital?

1[] Yes
2[] No (NP)

Ask for mother and child:
b. Have you included this hospitalization in the number you gave me for --?

1[] Yes (NP)
2[] No (Correct 6 and "HOSP." box)

[p. 143]

B. LIMITATION OF ACTIVITIES PAGE

B1

Refer to age

1[] 18-70 (1)
2[] Other (NP)

1. What was -- doing most of the past 12 months; working a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent most time doing; (2) Considers most important.

1[] Working (2)
2[] Keeping house (3)
3[] Going to school (5)
4[] Something else (5)

2a. Does any impairment or health problem now keep -- from working at a job or business?

1[] Yes (7)
[] No

b. Is -- limited in the kind or amount of work -- can do because of any impairment or health problem?

2[] Yes (7)
3[] No (6)

3a. Does any impairment or health problem now keep -- from doing any housework at all?

4[] Yes (4)
[] No

b. Is -- limited in the kind or amount of housework -- can do because of any impairment or health problem?

5[] Yes (4)
6[] No (5)

4a. What (other) condition causes this?
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago; For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question 3 where limitation reported, saying: Except for -- (condition), ...? or reask 4b/c.
(Enter condition in C2, THEN 4b)

1[] Old age (Mark "Old age" box, THEN 4c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 4a and b)
[] No (4d)

c. Is this limitation caused by any (other) specific condition?

[] Yes (Reask 4a and b)
[] No

Mark box if only one condition
d. Which of these conditions would you say is the main cause of this limitation?

[] Only 1 condition
________ Main cause

5a. Does any impairment or health problem keep -- from working at a job or business?

1[] Yes (7)
[] No

b. Is -- limited in the kind or amount of work -- could do because of any impairment or health problem?

2[] Yes (7)
3[] No

B2
Refer to questions 3a and 3b

1[] "Yes" in 3a or 3b (NP)
2[] Other (6)
6a. Is -- limited in any way in any activities because of an impairment or health problem?

1[] Yes
2[] No (NP)

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

________ Limitation

7a. What (other) condition causes this?
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago; For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question 3 where limitation reported, saying: Except for -- (condition), ...? or reask 7b/c.
(Enter condition in C2 , THEN 7b)

1[] Old Age (Mark "Old age" box, then 7c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 7a and b)
[] No (7d)

c. Is this limitation caused by any (other) specific conditions?

[] Yes (Reask 7a and b)
[] No

Mark box if only one condition.
d. Which of these conditions would you say is the main cause of this limitation?

[] Only 1 condition
________ Main cause

[p. 144]

B. LIMITATIONS OF ACTIVITIES PAGE, Continued

B3

Refer to age

0[] Under 5 (10)
1[] 5-17 (11)
2[] 18-59 (B4)
3[] 60-71 (14)
4[] 71 and over (8)

8. What was -- doing most of the past 12 months; working at a job or business, keeping house, going to school, or something else? Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

1[] Working
2[] Keeping house
3[] Going to school
4[] Something else


9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

1[] Yes (13)
[] No

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

2[] Yes (13)
3[] No (12)

10a. Is -- able to take part at all in the usual kinds of play activities done by most children -- age?

[] Yes
0 [] No (13)

b. Is -- limited to the kind or amount of play activities -- can do because of any impairment or health problem?

1[] Yes (13)
2[] No (12)

11a. Does any impairment or health problem now keep -- from attending school?

1[] Yes (13)
[] No

b. Does -- attend a special school or special classes because of any impairment or health problem?

2[] Yes (13)
[] No

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

3[] Yes (13)
[] No

d. Is -- limited in school attendance because of -- health?

4[] Yes (13)
5[] No

12a. Is -- limited in any way in any activities because of impairment or health problem?

1[] Yes
2[] No (NP)

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

________ Limitation

13a. What (other) condition causes this?
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago: For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question where limitation reported, saying: Except for -- (condition), ...? or reask 13b/c.
(Enter condition in C2, THEN 13b)

1[] Old age (Mark "Old age" box, THEN 13c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 13a and b)
[] No (13d)

c. Is this limitation caused by any (other) specific condition?

[] Yes (Reask 13a and b)
[] No

Mark box if only one condition.
d. Which of these conditions would you say is the main cause of this limitation?

[] Only 1 condition
________ Main cause

B4
Refer to "Age," "Old age," and "LA" boxes. Mark first appropriate box.

[] 5-59 and "Old age" box marked (14)
[] 5-59 and entry in "LA" box (14)
[] Other (NP)
14a. Because of any impairment or health problem, does -- need the help of persons in handling -- personal care needs, such as eating, bathing, dressing, or getting around this home?

1[] Yes (NP)
[] No

Ask if age 18 and over.
b. Because of any impairment or health problem, does -- need the help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

2[] Yes
3[] No

[p. 145]

D. RESTRICTED ACTIVITY PAGE PERSON 1

Hand calendar
{The next questions refer to the 2 weeks outlined in red on that calendar, beginning Monday, (date) and ending this past Sunday (date)}

D1

Refer to age.

[] Under 5 (4)
[] 5-17 (3)
[] 18 and over (1)


1a. During those 2 weeks, did -- work at any time at a job or business not counting work around the house? (Include unpaid work in the family [farm/business].)

1[] Yes (Mark "Wa" box, then 2)
2[] No

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

1[] Yes (Mark "Wb" box, then 2)
2[] No (4)


2a. During those 2 weeks, did -- miss any time from a job or business because of illness or injury?

[] Yes
00[] No (4)

b. During that 2-week period, how many days did -- miss more than half of the day from -- job or business because of illness or injury?

00[] None (4)
____ No. of work-loss days (4)


3a. During those 2 weeks, did -- miss any time from school because of illness or injury?

[] Yes
00[] No (4)

b. During that 2-week period, how many days did -- miss more than half of the day from school because of illness or injury?

00[] None
____ No. of school-loss days


4a. During those 2 weeks, did -- stay in bed because of illness or injury?

[] Yes
00[] No (6)

b. During that 2-week period, how many days did -- stay in bed more than half of the day because of illness or injury?

00[] None (6)
____ No. of bed days

D2

Refer to 2b and 3b

[] No days in 2b or 3b (6)
[] 1 or more days in 2b or 3b (5)

5. On how many of the (number in 2b or 3b) days missed from [work/school] did -- stay in bed more than half of the day because of illness or injury?

00[] None
____ No. of days


Refer to 2b, 3b and 4b.
6a. (Not counting the day(s) missed from work missed from school, (and) in bed ). Was there any (OTHER) time during those 2 weeks that -- cut down on the things -- usually does because of illness or injury?

[] Yes 00
[] No (D3)

b. (Again, not counting the day(s) missed from work, missed from school, (and) in bed)
During that period, how many (OTHER) days did -- cut down for more than half of the day because of illness or injury?

00[] None
____ No. of cut down days

D3
Refer to 2 - 6

[] No days in 2 - 6 (Mark "No" in RD, then NP)
[] 1 or more days in 2 - 6 (Mark "Yes" in RD, THEN 7)

Refer to 2b, 3b, 4b and 6b.
7a. What (other) condition caused -- to miss work, miss school, (or) stay in bed, (or) cut down during those 2 weeks?
[Enter condition in C2, then 7b]

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

1[] Yes (Reask 7a and b)
2[] No

[p. 148]

G. HEALTH INDICATOR PAGE

1a. During the past 2-week period outlined in red on that calendar, has anyone in the family had an injury from an accident or other cause that you have not yet told me about?

[] Yes
[] No (2)

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

[] Injury

c. What was -- injury?
Enter injury(ies) in person's column.

____ Injury

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

[] Yes (Reask 1b, c, and d)
[] No

Ask for each injury in 1c:
e. As a result of the (injury in 1c) did [--/anyone] see or talk to a medical doctor or assistant (about sample person) or did -- cut down on -- usual activities for more than half of a day?

[] Yes (Enter injury in C2, then 1e for next injury)
[] No (1e for next injury)


2. During the past 12 months, {that is, since (12-month date) a year ago} about how many days did illness or injury keep -- in bed more than half of the day? (Include days while an overnight patient in a hospital.)

000[] None
____ No. of days


3a. During the past 12 months, about how many times did [--/anyone] see or talk to a medical doctor or assistant (about sample person)? (Do not count doctors seen while an overnight patient in a hospital.) (Include the (number in 2-WK DV box) visit(s) you already told me about.)

000[] None (3b)
000[] Only when overnight patient in hospital (NP)
____ No. of visits

b. About how long has it been since [--/anyone] last saw or talked to a medical doctor or assistant (about sample person)? Include doctors seen while a patient in a hospital.

1[] Interview week (Reask 3b)
2[] Less than 1 yr. (Reask 3a)
3[] 1yr., less than 2 yrs.
4[] 2 yrs., less than 5 yrs.
5[] 5 yrs. or more
0[] Never


4. Would you say -- health in general is excellent, very good, fair, or poor?

1[] Excellent
2[] Very good
3[] Good
4[] Fair
5[] Poor


Mark box if under 18.
5a. About how tall is -- without shoes?

[] Under 18 (NP)
____ Feet
____ Inches


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

____ Pounds

[p. 149]

H. CONDITION LISTS 1 AND 2

Read to respondent(s) and ask list specified in A2:
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

1

1a. Does anyone in the family {read names} now have --?
If "Yes," ask 1b 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?

c. Does anyone else now have --?
Enter condition and letter in appropriate person's column.

d. During the past 12 months, did anyone in the family have --?
If "Yes," ask 1e and f.

c. Arthritis of any kind or rheumatism?
d. Gout?
e. Lumbago?
f. Osteomyelitis? (os-tee-oh-my-uh-lye'tis)
g. A bone cyst or bone spur?
h. Any other disease of the bone or cartilage?
i. A trick knee?
j. A slipped or ruptured disc?
k. Curvature of the spins?
l. Repeated trouble with neck, back, or spine?
m. Bursitis or synovitis? (sin-o-vye'tis)
n. Any disease of the muscle or tendons?
o. A tumor, cyst, or growth of the skin?
p. Eczema or Psoriasis? (ek'sa-ma) or (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?

f. During the past 12 months, , did anyone else have --?
Enter condition and letter in appropriate person's column.

C-N and V are conditions affecting the bone and muscle.
Conditions O-U and W-Z are conditions affecting the skin.

2

2a. Does anyone in the family {read names} now have --?
If "Yes," ask 2b 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 other 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; toes, foot, or leg?
n. A missing (breast), kidney, or lung?
o. Palsy or cerebral palsy? (ser'a-bral)
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 feet, leg, or back? (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 caused by an accident or injury which happened more than 3 months ago? If "Yes" ask: What is the condition?
y. Epilepsy?
z. Repeated convulsions, seizures, or blackouts?

b. Who is this?

c. Does anyone else now have --?
Enter condition and letter in appropriate person's column.

A-L are conditions affecting hearing, vision, speech
Conditions O-W are impairments
Conditions Y and Z affect the nervous system

[p.150]

H. CONDITION LISTS 3 AND 4

Read to respondent(s) and ask list specified in A2:
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

3
3a. During the past 12 months, did anyone in the family {read names} have --?
If "Yes," ask 3b 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. Any disease of the pancreas?
i. An ulcer?
j. A hernia or rupture?
k. Any disease of the esophagus?
l. Gastritis?
m. Frequent ingestion?
n. Any other stomach trouble?
o. Enteritis?
p. Diverticulitis? (Dye-ver-tic-yoo-lye'tis)
q. Colitis?
r. A spastic colon?
s. Frequent constipation?
t. Any other bowel trouble?
u. Any other intestinal trouble?
v. Cancer of the stomach, colon, or rectum?
w. During the past 12 months, did anyone (else) in the family have any other condition of the digestive system?
If "Yes" ask: Who was this? - What was the condition? Enter in the item C2. Then reask W.

b. Who was this?

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

Enter condition and letter in appropriate person's column.
Make no entry in item C2 for cold: flu: red, sore, or strep throat; or "virus" even if reported in this list.
Conditions affecting the digestive system.

4a. During the past 12 months, did anyone in the family {read names} have --?
If "Yes," ask 4b and c.

a. A goiter or other thyroid trouble? (Glandular disorders)
b. Diabetes? (Glandular disorders)
c. Cystic fibrosis? (Glandular disorders)
d. Anemia? (blood disorder)
e. Epilepsy? (Condition affecting the nervous system)
f. Multiple Sclerosis? (Condition affecting the nervous system)
g. Migraine? (Condition affecting the nervous system)
h. Neuralgia or Neuritis? (Condition affecting the nervous system)
i. Sciatica? (si-at i-kuh) (Condition affecting the nervous system)
j. Nephritis? (Genito-urinary conditions)
k. Kidney stones? (Genito-urinary conditions)
l. Any other kidney trouble? (Genito-urinary conditions)
m. Bladder trouble? (Genito-urinary conditions)
n. Prostate trouble? (Genito-urinary conditions)
o. Any disease of the uterus or ovary? (Genito-urinary conditions)
p. Any other female trouble? (Genito-urinary conditions)
q. Cancer of any kind?

b. Who was this?

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

Enter condition and letter in appropriate person's column.

[p. 151]

H. CONDITION LISTS 5 AND 6

Read to respondents(s) and ask list specified in A2.
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

5a. Has anyone in the family {read names} ever had --?
If "Yes." ask 5b 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. Hypertension, sometimes called High blood pressure?
g. Stroke or a Cerebrovascular accident? (ser'a-bro vas ku-lar)
h. A hemorrhage of the brain?
l. Angina pertoris? (pek'to-ris)
j. A myocardial infarction?
k. Any other heart attack?

b. Who was this?

c. Has anyone else ever had --?

Enter condition and letter in appropriate person's column.
Conditions affecting the heart and circulatory system.

5d. During the past 12 months, did anyone in the family have --?
If "Yes," ask 5e and f.

l. Damaged heart valves?
m. Tachycardia or rapid heart?
n. A heart murmur?
o. Any other heart trouble?
p. An aneurysm? (an-yoo-rixm)
q. Any blood clots?
r. Gangrene?
s. Varicose veins?
t. Hemorrhoids or Piles?
u. Phlebitis or thrombophlebitis?
v. Any other condition affecting blood circulation?

e. Who was this?

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

Enter condition and letter in appropriate person's column.
Conditions affecting the heart and circulatory system.

6

6a. During the past 12 months, did anyone in the family {read names} have --?
If "Yes," ask 6b and c.

a. Bronchitis?
b. Bronchietosis? (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. *Tonsilitis or enlargement of the tonsils or adenoids?
i. *Laryngitis?
j. A 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 work-related respiratory condition such as dust on the lungs, silicosis 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 C2, then reask Q.

b. Who was this?

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

Enter condition and letter in appropriate person's column.
Make no entry in item C2 for cold; flu; red sore, or strep throat; or "virus" even if reported in this list.
Conditions affecting the respiratory system.

* If reported in this list only, ask:

1. How many times did -- have (condition) in the past 12 months?
if 2 or more times, enter condition in item C2.
if only 1 times, ask:
2. How long did it last? If 1 months or longer, enter in item C2.
If less than 1 months, do not record.
If tonsils or adenoids were removed during past 12 months, enter the condition causing removal in item C2.
[p. 155]

L. DEMOGRAPHIC BACKGROUND PAGE


L1
Refer to age

[] Under 5 (NP)
[] 5-17 (2)
[] 18 and over (1)


1a. Did -- ever serve on active duty in the Armed Forces of the United States?

1[] Yes (Mark "AF" box, then 1b)
2[] No (2)

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
Other service (all other periods) .... OS
Mark box in descending order of priority.
Thus, if person served in Vietnam and in Korea, mark 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(2)
7[] DK(2)

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

1[] Y
3[] N
9[] DK


2a. What is the highest grade or year of regular school -- has ever attended?

00[] Never attended or kindergarten (NP)

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 (number in 2a) [grade/year]?

1[] Yes
2[] No


Hand Card R, Ask first alternative for first person, ask second alternative for other persons.
Card R

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

3a. [ What is the number of the group or groups which represents -- race?]
[What is -- race?]
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

1
2
3
4
5 ____

Ask if multiple entries:
b. Which of those groups; that is, (entries in 3a) would you say BEST describes -- race?

1
2
3
4
5 ____ (specify)

c. Mark observed race of respondent(s) only.

1[] W
2[] B
3[] O


Hand Card O
Card O

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

4a. Are any of those groups -- 's national origin or ancestry?
(Where did --'s ancestors come from?)

1[] Yes
2[] No (NP)

b. Please give me the number of the group
Circle all that apply.
1. Puerto Rican
2. Cuban
3. Mexican/Mexicano
4. Mexican American
5. Chicano
6. Other Latin American
7. Other Spanish

1
2
3
4
5
6
7

[p. 156]

L. Demographic Background Page, continued

L2


Refer to "Age" and "Wa/Wb" boxes in C1.

0[] Under 18 (NP)
1[] Wa box marked (6a)
2[] Wb box marked (5a)
3[] Neither box marked (5b)


5a. Earlier you said that -- has a job or business but did not work last week or the week before. Was -- looking for work or on layoff from a job during those 2 weeks?

1[] Yes (5c)
2[] No (6b)

b. Earlier you said that -- didn't have a job or business last week or the week before. Was -- looking for work or on layoff from a job during those 2 weeks?

1[] Yes
2[] No (NP)

c. Which, looking for work or on layoff from a job?

1[] Looking (6c)
2[] Layoff (6b)
3[] Both (6b)


6a. Earlier you said that -- worked last week or the week before. Ask 6b.

b. For whom did -- work? Enter name of company, business, organization or other employer.

Employer ________

c. For whom did -- work at -- last full-time civilian job or business lasting 2 consecutive weeks or more? Enter name of company, business, organization, or other employer.

Employer ________

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

Industry ________

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

Occupation ________

f. 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 6b-f. If not clear ask:
g. 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, ask is the business incorporated?
Yes ....I
No (or farm) ....SE
Working without pay in family business or farm? .... WP
Never worked or never worked at a full-time civilian job lasting 2 weeks or more .... NEV
Class of worker

1[] P
2[] F
3[] S
4[] L
5[] I
6[] SE
7[] WP
8[] NEV

[p.157]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued


Mark box if under 14. If "Married" refer to household composition and mark accordingly.
7. Is -- now married, widowed, divorced, separated, or has -- never been married?

0[] Under 14
1[] Married - spouse in HH
2[] Married - spouse not in HH
3[] Widowed
4[] Divorced
5[] Separated
6[] Never married


8a. Was the total combined family income during the past 12 months - that is, yours, (read names, including Armed Forces members living at home) more or less than $20,000? Include money from jobs, social security, retirement income, unemployment payments, public assistance, and so forth. Also include income from interest, dividends, net income from business, farm, or rent, and any other money income received.
Read if necessary: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical care services or have certain conditions more or less often than those in another group.

1[] $20,000 or more (Hand Card I)
2[] Less than $20,000 (Hand Card J)
Card I
U ........ 20,00-24,999
V ........ 25,000-29,999
W ....... 30,000-34,999
X ........ 35,000-39,999
Y ........ 40,000-44,999
Z ........ 45,000-49,999
ZZ ..... 50,000 and over
Card J
A ......... Less thank 1,000 (including loss)
B ......... 1,000 - 1,999
C ......... 2,000 - 2,999
D ......... 3,000 - 3,999
E .......... 4,000 - 4,999
F .......... 5,000 - 5,999
G ......... 6,000 - 6,999
H ......... 7,000 - 7,999
I .......... 8,000 - 8,999
J ......... 9,000 - 9,999
K ........ 10,000 - 10,999
L ........ 11,000 - 11,999
M ....... 12,000 - 12,999
N ........ 13,000 - 13,999
O ........ 14,000 - 14,999
P ......... 15,000 - 15,999
Q ........ 16,000 - 16,999
R ........ 17,000 - 17,999
S ........ 18,000 - 18,999
T ........ 19,000 - 19,999

Read parenthetical phrase if Armed Forces member living at home or if necessary.
b. Of those income groups, which letter best represents the total combined FAMILY income during the past 12 months (that is, yours, (read names, including Armed Forces members living at home))? Include wages, salaries, and the other items we just talked about.
Read if necessary: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical care services or have certain conditions more or less often than those in another group.

00[] A
01[] B
02[] C
03[] D
04[] E
05[] F
06[] G
07[] H
08[] I
09[] J
10[] K
11[] L
12[] M
13[] N
14[] O
15[] P
16[] Q
17[] R
18[] S
19[] T
20[] U
21[] V
22[] W
23[] X
24[] Y
25[] Z
26[] ZZ


R
a. Mark first appropriate box.

0[] Under 17
1[] Present for all question
2[] Present for some questions
3[] Not present

b. Enter person number of respondent.

____ Person Number(s) of respondent (s)