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[p.145]

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 ____

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)

________
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 procedures it 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, 3, 9 as applicable. 10, 12-15)
06[] Vacant -seasonal (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
07[] Occupied entirely by persons with URE (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
08[] Occupied entirely by Armed Forces members (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
09[] Unfit or to be demolished (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
10[] Under construction, not ready (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
11[] Converted to temporary business or storage (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
12[] Unoccupied tent site or trailer site (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
13[] Permit granted, construction not started (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
14[] Other (Specify) ____ (Fill items, 1-6a, 7, 3, 9 as applicable. 10, 12-15)
Type C
15[] Unused line of listing sheet (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
16[] Demolished (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
17[] House or trailer moved (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
18[] Outside segment (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
19[] Converted to permanent business or storage (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
20[] Merged (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
21[] Condemned (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
22[] Built after April 1, 1970 (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)
23[] Other (Specify) ____ (Fill items 1-6a, 8c if marked, 12-15, Send Inter-Comm)


15. 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)
____

16. List column numbers of persons requiring callbacks
[option for three records in the original document not presented here]

[] None
Col. No
____
Dental Required
[] Yes
[] No
Alcohol Required
[] Yes
[] No

17. Record of additional contacts
[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 Col. No
D ____
A ____

[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 any description of location

________
________
________

Location of Unit
2. Is this unit in a special place?

[] Yes - Skip to col. (6) and mark according to Table D in Part C of manual
[] No

Separateness and facilities
3.Do the occupants (or intended occupants) of (address in col. (1)) live and eat separately from all other persons on the property?

[] Yes
[] No-skip tp col. (6) 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
6. 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.

[] N- Stop 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 within the segment boundaries?

[] Yes- interview as an Extra unit
[] No- do not interview

Address, Cen-Sup and Special place segments
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 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 an Extra unit
[] No- Do no interview

NOTE: Be sure to continue interview for original sample unit after completing table x for all times

[p.164]

FORM HIS-1 (SB) (1983)
(3 14 83)


NATIONAL HEALTH INTERVIEW SURVEY
SUPPLEMENT BOOKLET

1. Book ____ of ____ books

2. R.O. number

____

3. Sample

____

4. Control number

PSU ____
Segment ____
Serial ____

5. Interviewer's name

Code ____

6. Status of supplements

1[] Complete interview (all appropriate pages completed)
2[] Partial interview (some but not all appropriate pages completed) (Explain in footnotes)
3[] Noninterview .... (Explain in footnotes)

Footnotes

____
7. Use Flashcard X, Y, or Z as indicated on HIS-1 Household Composition Page.
Circle that letter below. Also, circle the total number of person.

Card X

If the number of persons is -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
the following person (s) will be the sample person(s):
-
1
3
2
1 and 4
3 and 6
2 and 5
1, 4, and 7
3, 6, and 9
2, 5, and 8
1, 4, 7 and 10
3, 6,9, and 12
2, 5, 8, and 11
1, 4, 7,,10, and 13
3, 6, 9, 12, and 15

Card Y

If the number of persons is
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
the following person(s) will be the sample person(s):
-
2
1
3
2 and 5
1 and 4
3 and 6
2, 5 and 8
1, 4 and 7
3, 6 and 9
2, 5, 8 and 11
1, 4, 7 and 10
3, 6, 9 and 12
2, 5, 8, 11 and 14
1, 4, 7, 10 and 13

Card Z

If the number of persons is -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
The following person(s) will be the sample person(s):
1
-
2
1 and 4
3
2 and 5
1, 4, and 7
3 and 6
2, 5 and 8
1, 4,7 and 10
3, 6, and 9
2, 5, 8 and 11
1, 4, 7, 10 and 13
3, 6, 9 and 12
2, 5, 8, 11 and 14

If more than 15 persons, call your regional office for sample person selection instructions.