[p.145]
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 ____
6a. What is your exact address? (Including House No., Apt. No., or other identification; county and ZIP code)____
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 AND BLOCK SEGMENTS
[] Do not ask
When was this structure originally built?
[] After 4-1-80 (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
[] No
[] No
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?
2 [] No (10)
10. CLASSIFICATION OF LIVING QUARTERS -- Mark by observation
a. LOCATION of unit
2 [] NOT in a Special Place (10b)
b. Access
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)
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 _ _ _ -_ _ _-_ _ _ _
2 [] No
b. Language of interview
2 [] Spanish
3 [] Both English and Spanish
8 [] Other
(Fill items 1-6a, 7 and 9 as applicable; 10, 12-15)
02 [] No one at home, repeated calls
03 [] Temporarily absent -- Footnote
04 [] Other (Specify)____
(Fill items 1-6a, 7-9 as applicable; 10, 12-15)
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) ____
(Fill 1-5a, 8c if marked; 12-15, send Inter-Comm.)
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
[Calls 1-6]
Date ____
Beginning time
[] p.m.
[] p.m.
16. List column numbers of persons requiring callbacks, and mark appropriately.
Col No. ____
S.S. No. ____
Sect. M ____
Sect. N ____
SP ____
17. Record of additional contacts
Date ____
Beginning time
[] p.m.
[] p.m.
[p. 167]
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 ____
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.