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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.143]

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
[] Block

5. Control number

PSU ____
Segment ____
Serial ____

LISTING SHEET

Sheet ____
Line No. ____

6a. What is your exact address? (Including House No., Apt. No., or other identification; county and ZIP code) ____

City ____
State ____
County ____
ZIP Code ____

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 AND BLOCK SEGMENTS

7. YEAR BUILT

[] Ask
[] Do not ask
When was this structure originally built?
[] Before 4-1-80 (Continue interview)
[] After 4-1-80 (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 A in Part C of manual; then complete 10c or d
2[] NOT in a Special Place (10b)
b. Access
1[] Direct (10c)
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.)


c. 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


d. OTHER unit (Mark one)
08 [] Quarters not HU in rooming or boarding house
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?

0 [] None
Area code/number _ _ _-_ _ _ -_ _ _ _

12. Was this interview observed?

1 [] Yes
2 [] No

13a. Interviewer's name ____

Code ____

b. Language of interview

1 [] English
2 [] Spanish
3 [] Both English and Spanish
8 [] Other


14. Noninterview reason

TYPE A
01 [] Refusal -- Describe in footnotes
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) ____

TYPE B
05 [] Vacant -- nonseasonal
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) ____
TYPE C
15 [] Unused line of listing sheet
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.]

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, and mark appropriately.

[] None
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.]

Month ____
Date ____
Beginning time ____
[] a.m.
[] p.m.
[] P
[] T
Ending time ____
[] a.m.
[] p.m.
Completed Col. No. ____

hh
[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

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.____

Sheet ____
Line ____

LOCATION OF UNIT

2. Is this unit in a special place?

[] Yes - Skip to col. (5) and mark according to Table A 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 to col. (5) and Mark N

4. Does (address in Col. (1)) have direct access from the outside or through a common hall?

[] Yes - Mark HU in col. (5)
[] 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.

[] N - Stop Table X for this line
[] 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?

[] Yes - Interview as an EXTRA unit
[] No - Do not interview

PERMIT SEGMENTS

7. Is this unit within the same structure as the original sample unit?

[] Yes - List on first available line of listing sheet. Interview if in sample.
[] 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

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

Last name ____
First name ____

8. FINAL STATUS OF SUPPLEMENTS

0 [] No person 18+ in this family (Household page)

a. Section M (Household Respondent section)

Interview
1 [] Complete interview (all appropriate items completed)
2 [] Partial interview (some but not all appropriate items completed) (Explain in notes)
Noninterview
3 [] Refusal (Explain in notes)
4 [] Other (Explain in notes)
b. Sections N through V (Sample Person Section)

Interview
1 [] Complete interview (all appropriate sections completed)
2 [] Partial interview (some but not all appropriate sections completed) (Explain in notes)
Noninterview
3 [] Refusal (Explain in notes)
4 [] SP temporarily absent
5 [] Mentally or physically incapable
8 [] Other (Explain in notes)

9. Beginning time ____

1 [] a.m.
2 [] p.m.

Ending time ____

1 [] a.m.
2 [] p.m.

10. Interviewer identification

Name ____
Code ____

11. FAMILY ROSTER

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.

[Lines 1-9]

Person No. ____
Name ____
Age ____

TRANSCRIPTION FROM COMPLETED HIS-1


12. Telephone in household (Household page, question 11, THEN 16)

1 [] Yes
2 [] No
9 [] DK

13. Education of SP (page 42, question 2a)

00 [] Never attended or kindergarten

Elem:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High:
[] 9
[] 10
[] 11
[] 12
College
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

Finish grade/year (Question 2b)

1 [] Yes
2 [] No

14. Main Race of SP (page 42, question 3a/b)

[] 1
[] 2
[] 3
[] 4
[] 5 -- Specify ____

15. Family income (page 46, question 8b)

00 [] A
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


16. TELEPHONE NUMBER

[] None
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).