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[p.146]


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 ____

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 ____
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 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

13. Interviewer's name ____

Code ____


14. Noninterview reason

TYPE A
(Fill items 1-6a, 7 and 9 as applicable; 10, 12-15)
01 [] Refusal -- Describe in footnotes
02 [] No one at home, repeated calls
03 [] Temporarily absent -- Footnote
04 [] Other (Specify)____

TYPE B
(Fill items 1-6a, 7-9 as applicable; 10, 12-15)
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
12 [] Unoccupied site for mobile home, trailer or tent
13 [] Permit granted, construction not started
14 [] Other (Specify) ____
TYPE C
(Fill 1-5a, 8c if marked; 12-15, send Inter-Comm.)
15 [] Unused line of listing sheet
16 [] Demolished
17 [] House or trailer moved
18 [] Outside segment
19 [] Converted to permanent business or storage
20 [] Merged
21 [] Condemned
22 [] Built after April 1, 1980
23 [] Other (Specify) ____


15. Record of calls

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 P ____
SP ____

17. Record of additional contacts

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

[p. 166]

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

[Table X has allows for 3 different responses with regards to identical questions. Only one line indicated here.]

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


[End Table X]

NOTE: Be sure to continue interview for original unit after completing Table X for all lines.

[p.167]


National Health Interview Survey
Supplement Booklet

1. Book ____ of ____ books

2. R.O. Number ____

3. Sample ____

4. Control number

PSU ____
Segment ____
Serial ____

5. Beginning time ____

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

VITAMIN AND MINERAL INTAKE SAMPLE SELECTION

6. Are there any nondeleted children 2-6 years old in this family?

1 [] Yes (List by age (oldest to youngest) in Table A, THEN 7)
2 [] No (7)

7. Are there any nondeleted persons 18+ years old in this family?

1 [] Yes (List by age (oldest to youngest) in Table B)
2 [] No

8.
TABLE A (2-6 year olds)
[Lines 1-9]

Line no. ____
Person No. ____
Name ____
Age ____

TABLE B (18 +)
[Lines 1-9]

Line no. ____
Person No. ____
Name ____
Age ____

Refer to the appropriate sections of the sample person selection label and circle as applicable. THEN circle Person No. in TABLE A and/or TABLE B and mark the "SP" box(es) on the HIS-1 for the selected sample person(s). THEN go to Section N.

9. FINAL STATUS OF SUPPLEMENTS

a. Sections N and O (Household Respondent 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)
8 [] Other (Explain in notes)

b. Section P (Eligible Person Section)

0 [] No person 65+ in this family
1 [] All eligible persons interviewed
2 [] Some but not all eligible persons interviewed (Explain in notes)
3 [] No eligible persons interviewed (Explain in notes)

c. Section Q (Child Sample Person Section)

0 [] No child 2-6 in this family
1 [] Interview
2 [] Noninterview (Explain in notes)

d. Section Q (Adult Sample Person Section)

0 [] No person 18+ in this family
1 [] Interview
Noninterview
2 [] Refusal (Explain in notes)
3 [] SP temporarily absent
4 [] SP mentally or physically incapable
8 [] Other (Explain in notes)

10. Ending time ____

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

11. Interviewer identification

Name ____
Code ____