[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 ____
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
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?
[] 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
02 [] No one at home, repeated calls [Fill items 1-6a, 7 and 9 as applicable; 10. 12-15]
03 [] Temporarily absent -- Footnote [Fill items 1-6a, 7 and 9 as applicable; 10. 12-15]
04 [] Other (Specify) ____ [Fill items 1-6a, 7 and 9 as applicable; 10. 12-15]
06 [] Vacant -- seasonal [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
07 [] Occupied entirely by persons with URE [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
08 [] Occupied entirely by Armed Forces members [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
09 [] Unfit or to be demolished [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
10 [] Under construction, not ready [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
11 [] Converted to temporary business or storage [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
12 [] Unoccupied site for mobile home, trailer or tent [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
13 [] Permit granted, construction not started [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
14 [] Other (Specify) ____ [Fill items 1-6a, 7-9 as applicable; 10, 12-15]
16 [] Demolished [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
17 [] House or trailer moved [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
18 [] Outside segment [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
19 [] Converted to permanent business or storage. [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
20 [] Merged [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
21 [] Condemned [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
22 [] Built after April 1, 1980 [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
23 [] Other (Specify) ____ [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
15. Record of calls
[option for 6 entries in original document not presented here : that is calls 1-6]
Date ____
Beginning time
[] p.m.____
[] p.m.____
16. List column numbers of persons requiring callbacks, and mark appropriately.
[option for 3 entries in original document not presented here]
Col No. ____
S.S. No. ____
Sect. M ____
Sect. N ____
Sect. O ____
Sect. P____
AIDS____
17. Record of additional contacts
[option for 4 entries in original document not presented here]
Date ____
Beginning time
[] p.m.____
[] p.m.____
[p. 165]
E
If this questionnaire is for an EXTRA unit, enter Control Number of original sample unit. ____
If in area or block segment, also enter for FIRST unit listed on property
Listing sheet
Line number ____
[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.
[p. 166]
NATIONAL HEALTH INTERVIEW SURVEY : SUPPLEMENT BOOKLET
Segment ____
Serial ____
2[] p.m. ____
CHILD AND ADULT SAMPLE SELECTION
6. Are there any nondeleted children 0-17 years old in this family?
2 [] No (7)
7. Are there any nondeleted persons 18+ years old in this family?
2 [] No
8. TABLE A (0-17 year olds)
[option for 9 entries in the original document not presented here]
1. Line no
Name ____
Sex
2[] F
2[] Yrs ____
TABLE B (18+):
[option for 9 entries in the original document not presented here]
1. Line no
Name ____
Sex
2[] F
Refer to the appropriate section of the sample person selection and 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. THEN go to Section M.
9. Final status of supplement
a. Section M (page 2) (Medical Device Implant)
1 [] Complete interview (all persons with MDIs interviewed)
2 [] Partial interview (some but not all persons with MDIs interviewed) (Explain in notes)
3 [] Partial interview (Persons with MDIs not interviewed) (Explain in notes)
8 [] Other (Explain in notes)
b. Section N (Occupational health)
[] Interview
2 [] Partial interview (some but not all appropriate sections completed) (Explain in notes)
4 [] SP temporarily absent
5 [] SP mentally or physically incapable
8 [] Other (Explain in notes)
c. Section O (page 68) (Alcohol)
[] Interview
2[] Partial interview (some but not all appropriate sections or HIS-2/HIS-3 completed) (Explain in notes)
4[] SP temporarily absent
5[] SP mentally or physically incapable
8[] Other (Explain in notes)
d. Section P (page 86) (Child Health)
[] Interview
2[] Partial interview (some but not all appropriate sections completed) (Explain in notes)
4[] Eligible Resp. TA
5[] No eligible resp. in HHld.
8[] Other (Explain in notes)
2[] p.m. ____
11. Interviewer identification
Code ____