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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.149]


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)

[ ] 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 procedures if additional living quarters space was listed separately)
[] None (Not a separate HU: combine with unit through which access is gained. (Apply merged unit procedures 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, 9c. If marked, 12-15, send inter-comm)
16[] Demolished (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
17[] House or trailer moved (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
18[] Outside segment (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
19[] Converted to permanent business or storage. (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
20[] Merged (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
21[] Condemned (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
22[] Built after April 1, 1970 (Fill items 1-6a, 9c. If marked, 12-15, send inter-comm)
23[] Other (Specify) ____ (Fill items 1-6a, 9c. 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 for "Supplement on Aging"

[] None

Column Number
____
____
____

17. Record of additional contacts

[Options for four 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
____

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[pg.171]


NATIONAL HEALTH INTERVIEW SURVEY
SUPPLEMENT BOOKLET

1. Book ____ of ____ books

2. R.O. Number

____

3. Sample

____

4. Control number

PSU ____
Segment ____
Serial ____

5. Person number

____

6. Sex

1[] Male
2[] Female

7. Sample Person name

Last ____
First ____
Middle initial ____

8. Final status of supplement

0 [] No SP selected
Interview
1[] Complete interview (all appropriate pages completed)
2[] Partial interview (some but not all appropriate pages completed) (Explain in notes)

Noninterview
3[] Refused (Explain in notes)
4[] SP temporarily absent, no proxy available
5[] SP mentally or physically incapable, no proxy available
8[] Other (Explain in notes)

9. Date supplement completed

Month ____
Date ____

10. Interviewer identification

Name ____
Code ____

CONTACT PERSON INFORMATION

[] Contact information for this family unit already obtained, transcribe when editing. Fill item 15 below, THEN go to HIS-1 Household Page or next SOA.
Read to SOA respondent at end of interview - The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the name, address, and telephone number of a close relative or friend who would know where you could be reached in case we have trouble reaching you. (Please give me the name of someone who is not currently living in the household.) Please print items 11, 12, 14.

11. Contact Person name

Last ____
First ____
Middle initial ____

12a. Address (Number and street)

________

b.

City ____
State ____
Zip code ____

13. Area code/telephone number

_ _ _ _ _ _ _ _ _ _
1[] None
2[] Refused
9[] DK

14. Relationship to Sample Person

____

15. Supplement ending time

Hour ____
Minutes ____
1[] am (Go to HIS-1 household page or next SOA)
2[] pm (Go to HIS-1 household page or next SOA)

TRANSCRIPTION FROM HIS-1

16. Area code/telephone number from HIS-1, item 11

_ _ _ _ _ _ _ _ _ _
1[] None
2[] Refused

17a. Exact address from HIS-1, item 6a (Please print items 17a-c)
Number and street/description

________
City ____
State ____
Zip Code ____

b. Mailing address from HIS-1, item 6b
1[] Same as 6a on HIS-1 [5]

Number and street ________
City ____
State ____
Zip Code ____

c. Special Place name (Fill if applicable)

____

SUPPLEMENT ON AGAING SAMPLE SELECTION

Use Table A or B as indicated on HIS-1 Household Composition Page. Circle that letter and enter number below to indicate the order of interview (1 = down from the top of the listing, 2 = up from the bottom). Follow this order whenever two or more sample persons are at home at the same time.

18. Are there any nondeleted persons 65 years or older in the family?

1[] Yes (List by age (oldest to youngest) in upper portion of appropriate table, mark "SP" box on HIS-1 for each, then 19)
2[] No (19)

19. Are there any nondeleted persons 55-64 years old in the family?

1[] Yes
2[] No (Begin interview(s) using the appropriate "order of interview")

TABLE A _______

Age

____
____
____
____
____
____
____
____

Name

____
____
____
____
____
____
____
____

Person Number

____
____
____
____
____
____
____
____

Sample person

x
x
x
x
x
(no entry)
x
(no entry)
TABLE B _______

Age

____
____
____
____
____
____
____
____

Name

____
____
____
____
____
____
____
____

Person Number

____
____
____
____
____
____
____
____

Sample person

x
x
x
x
(no entry)
x
(no entry)
x