[p.149]
Appendix III. Questionnaire and Flash Cards
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
National Health Interview Survey
[] Permit
[] Address
[] Cen-Sup
[] Special Place
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
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
Type code ____
Area segments only
[] Do not ask
When was this structure originally built?
[] After 4-1-70 (Complete item 8c when required; end interview)
[] Do not ask
a. [] Are there any occupied or vacant living quarters besides your own in this building?
[] No
b. [] Are there any occupied or vacant living quarters besides your own on this floor?
[] No
c. [] Is there any other building on this property for people to live in, either occupied or vacant?
[] No
2[] Rural
- 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?
2[] No (10)
10. Classification of living quarters (Mark by observation)
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)
2[] Through another unit (10c)
[] 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)
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
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?
Area code _ _ _
Number _ _ _ _ _ _ _
12. Was this interview observed?
2[] No
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)
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)
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.]
Date ____
p.m ____
p.m ____
16. List column numbers of persons requiring callbacks for "Supplement on Aging"
Column Number
____
____
17. Record of additional contacts
[Options for four call records in original document -- not presented here.]
Date ____
p.m ____
p.m ____
[pg.171]
NATIONAL HEALTH INTERVIEW SURVEY
SUPPLEMENT BOOKLET
Segment ____
Serial ____
2[] Female
First ____
Middle initial ____
Interview
2[] Partial interview (some but not all appropriate pages completed) (Explain in notes)
Noninterview
4[] SP temporarily absent, no proxy available
5[] SP mentally or physically incapable, no proxy available
8[] Other (Explain in notes)
Date ____
10. Interviewer identification
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.
First ____
Middle initial ____
12a. Address (Number and street)
b.
State ____
Zip code ____
13. Area code/telephone number
1[] None
2[] Refused
9[] DK
14. Relationship to Sample Person
Minutes ____
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]
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?
2[] No (19)
19. Are there any nondeleted persons 55-64 years old in the family?
2[] No (Begin interview(s) using the appropriate "order of interview")
TABLE A _______
Age
____
____
____
____
____
____
____
Name
____
____
____
____
____
____
____
Person Number
____
____
____
____
____
____
____
Sample person
x
x
x
x
(no entry)
x
(no entry)
Age
____
____
____
____
____
____
____
Name
____
____
____
____
____
____
____
Person Number
____
____
____
____
____
____
____
Sample person
x
x
x
(no entry)
x
(no entry)
x