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[p. 146]

A. HOUSEHOLD COMPOSITION PAGE

[] SP
[] Old age
[] BD
[] AF

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.

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:

.

d. Do all of the persons you have named usually live here?

Probe if necessary.

Ask for all persons beginning with column 2:
2. What is -- relationship to (reference person) ?

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

A1

A2A3
Refer to ages of all related HH members

C1C24a. Are any of the persons in this household now on full-time active duty with the armed forces?

b. Who is this?

c. Anyone else?

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

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?

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

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

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

[p. 147]

B. LIMITATION OF ACTIVITIES PAGE

B1

Refer to age

1. 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 most time doing; (2) Considers most important.

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

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

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

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

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)

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

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

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

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

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

B2
Refer to questions 3a and 3b

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.

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)

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

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

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

[p.148]

B. LIMITATIONS OF ACTIVITIES PAGE, Continued

B3

Refer to age

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.

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

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?

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

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

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

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

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

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

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

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

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)

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

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

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

[p. 149]

B. LIMITATION OF ACTIVITIES PAGE, Continued

B4
Refer to age

B5
Refer to "Old age" and "LA" boxes. Mark first appropriate box.

14a. 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?

If under 18, skip to next person; otherwise ask:
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?

15a. 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 14 where limitation reported, saying: Except for -- (condition), ...? or reask 15b/c.
(Enter condition in C2, then 15b)

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

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

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

[p. 150]

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.

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]).

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

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

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?

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

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

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

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

D2
Refer tp 2b and 3b

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?

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?

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?

D3
Refer to 2 - 6

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?

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

[p. 153]

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?

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

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

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

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 --) or did -- cut down on -- usual activities for more than half of a day?

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.)

3a. During the past 12 months, about how many times did [--/anyone] see or talk to a medical doctor or assistant (about --)? (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.)

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.

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

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

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

[p.154]

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.

b. Who is this?

c. Does anyone else now have --?

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

e. Who was this?

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

2

2a. Does anyone in the family {read names} now have --?
If "Yes," ask 2b and c.

b. Who is this?

c. Does anyone else now have --?

[p. 155]

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.

b. Who was this?

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

4

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

b. Who was this?

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

[p. 156]

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.

5

5a. Has anyone in the family {read names} ever had --?
If "Yes." ask 5b and c.

b. Who was this?

c. Has anyone else ever had --?

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

e. Who was this?

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

6

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

b. Who was this?

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

* If reported in this list only, ask:

[p. 160]

L. DEMOGRAPHIC BACKGROUND PAGE

L1
Refer to age.

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

b. When did -- serve?
Vietnam Era (Aug. '64 to April ' 75) ....VN
Korean War (June '50 to Jan. '55) .... KW
World War II (Sept. '40 to July '47) ....WWII
World War I (April '17 to Nov, '18) ....WWI
Post Vietnam (May '75 to present) .... PVN
Other service (all other periods) .... OS

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

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

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

b. Did -- finish the (number in 2a) [grade/year]?

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

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

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

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

Hand Card O - Mark box or ask:
Card O

4a. 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/Mexicano
4- Mexican American
5-Chicano
6-Other Latin American
7-Other spanish

[p. 161]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued

L2

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

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?

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?

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

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

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.

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

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

f. 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 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, 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

[p. 162]

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?

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.

Card ICard J

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.

R
a. Mark first appropriate box.

b. Enter person number of respondent.