[p.143]
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
[] Block
Segment ____
Serial ____
LISTING SHEET
Line No. ____
6a. What is your exact address? (Including House No., Apt. No., or other identification; county and ZIP code) ____
State ____
County ____
ZIP Code ____
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 AND BLOCK SEGMENTS
[] Do not ask
[] After 4-1-80 (Complete item 8c when required; end interview)
[] Do not ask
[] No
[] No
[] 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 A in Part C of manual; then complete 10c or d
2[] NOT in a Special Place (10b)
2[] Through another unit -- Not a separate HU; combine with unit which through 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 site for mobile home, trailer, or tent
11 [] Student quarters in college dormitory
12 [] 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
b. Language of interview
2 [] Spanish
3 [] Both English and Spanish
8 [] Other
02 [] No one at home, repeated calls Fill items 1-6a, 7 and 9 as applicable; 10. 12-15
03 [] Temporarily absent -- Footnote
04 [] Other (Specify) ____
06 [] Vacant -- seasonal
07 [] Occupied entirely by persons with URE
08 [] Occupied entirely by Armed Forces members
09 [] Unfit or to be demolished
10 [] Under construction, not ready
11 [] Converted to temporary business or storage Fill items 1-6a, 7-9 as applicable;
12 [] Unoccupied site for mobile home, trailer or tent 10, 12-15
13 [] Permit granted, construction not started
14 [] Other (Specify) ____
16 [] Demolished
17 [] House or trailer moved
18 [] Outside segment Fill items 1-6a, 8c if marked; 12-15. send
19 [] Converted to permanent business or storage Inter- Comm.
20 [] Merged
21 [] Condemned
22 [] Built after April 1, 1980
23 [] Other (Specify) ____
15. Record of calls
[Survey shows lines for 6 callbacks. Only one line is indicated here.]
Date ____
Beginning time ____
[] p.m.
[] p.m.
16. List column numbers of persons requiring callbacks, and mark appropriately.
Col No. ____
S.S. No. ____
Section M ____
SP _____
17. Record of additional contacts
[Survey form indicates 4 additional lines with identical information, only one is indicated here.]
Date ____
Beginning time ____
[] p.m.
[] P
[] T
[] p.m.
[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
Line Number ____
ADDRESS OF ADDITIONAL LIVING QUARTERS
1. If already listed, fill sheet and line number below and stop Table X. Otherwise, enter basic address and unit address, if any, OR description of location.____
Line ____
LOCATION OF UNIT
2. Is this unit in a special place?
[] 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?
[] No - Skip to col. (5) and Mark N
4. Does (address in Col. (1)) have direct access from the outside or through a common hall?
[] No - Mark N in col. (5)
CLASSIFICATION
5. 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.
[] HU - Fill col. (6) or (7) as appropriate
[] OT - Fill col. (6) or (7) as appropriate
AREA AND BLOCK SEGMENTS
6. Is this unit within the segment boundaries?
[] No - Do not interview
PERMIT SEGMENTS
7. Is this unit within the same structure as the original sample unit?
[] No - Do not interview
NOTE: Be sure to continue interview for original unit after completing Table X for all lines.
[p. 164]
National Health Interview Survey
Health Promotion and Disease Prevention Supplement Booklet
4. Control number ____
PSU ____
Segment ____
Serial ____
2 [] Female
First name ____
8. FINAL STATUS OF SUPPLEMENTS
a. Section M (Household Respondent section)
Interview
2 [] Partial interview (some but not all appropriate items completed) (Explain in notes)
4 [] Other (Explain in notes)
Interview
2 [] Partial interview (some but not all appropriate sections completed) (Explain in notes)
4 [] SP temporarily absent
5 [] Mentally or physically incapable
8 [] Other (Explain in notes)
2 [] p.m.
Ending time ____
2 [] p.m.
10. Interviewer identification
Code ____
List all nondeleted family members 18+ by age (oldest to youngest). Refer to sample selection label and circle as appropriate. THEN circle Person No. In item 11 and mark "SP" box on HIS-1 for the selected sample person
Line no.
Person No. ____
Name ____
Age ____
TRANSCRIPTION FROM COMPLETED HIS-1
12. Telephone in household (Household page, question 11, THEN 16)
2 [] No
9 [] DK
13. Education of SP (page 42, question 2a)
Elem:
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 10
[] 11
[] 12
[] 2
[] 3
[] 4
[] 5
[] 6+
Finish grade/year (Question 2b)
2 [] No
14. Main Race of SP (page 42, question 3a/b)
[] 2
[] 3
[] 4
[] 5 -- Specify ____
15. Family income (page 46, question 8b)
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
27 [] $20,000 or more
28 [] Less than $20,000
Area Code Number _ _ _-_ _ _-_ _ _ _
Refer to HIS-1(SB) page 4, questions 4a and b. Transcribe from HIS-1 for the sample person, if required (page 20, questions 5a and b).