Data Cart

Your data extract

0 variables
0 samples
View Cart



hh
[p.144]

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. 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. 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 [Fill items 1-6a, 7 and 9 as applicable; 10, 12-15]
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]

TYPE B
05[] Vacant -- nonseasonal [Fill items 1-6a, 7-9 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]

TYPE C
15[] Unused line of listing sheet [Fill items 1-6a, 8c if marked; 12-15 , send inter-comm]
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]

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 indicated reason(s).

[] None

[] Household Resp:
Col. No ____
SS. No. ____
Sect M-O1 ____
[] Diabetic
Sect. O2 ____
[] Sample person
Sect. R-f ____
AIDS ____

17. Record of additional contacts

[option for 4 entries in original document not presented here]

Month ____
Date ____

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

[p.164]

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

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

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

[p. 165]


National Health Interview Survey:
1989 Current Health Topics

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. ____

Adult Family Roster

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

1[] Yes (List by age, oldest to youngest)
2[] No (Section M)


[Option for 9 entries in the original document not presented here]

1. Line no [SP]

Person no. ____
Name ____
Age ____

Sex
1[] M
2[] F
Name ____

Refer to the sample person selection label and circle as applicable. Then circle Person Number in item 6 and mark the "SP" box on the HIS-1 for the selected sample person. Then go to Section M.

7. Final Status
a. Household respondent

M. Health Insurance
Mark as appropriate.

1[] Complete interview
2[] Partial interview [explain in notes]

[] Non interview
3[] Refusal [explain in notes]
8[] Other (Explain in notes]
N. Immunization
Mark as appropriate

0[] No person 18+ in this family
1[] Complete interview
2[] Partial interview [explain in notes]

[] Noninterview
3[] Refusal [explain in notes]
8[] Other [explain in notes]
O. Mental health
1[] Complete interview
2[] Partial interview [explain in notes]

[] Non interview
3[] Refusal [explain in notes]
8[] Other (Explain in notes]
P. Dental
1[] Complete interview
2[] Partial interview [explain in notes]

[] Non interview
3[] Refusal [explain in notes]
8[] Other (Explain in notes]
Q1. Diabetes Screening
0[] No person 18+ in this family
1[] Complete interview
2[] Partial interview [explain in notes]

[] Noninterview
3[] Refusal [explain in notes]
8[] Other [explain in notes]

b. Household Diabetic(s)
Section Q2 (page 32) (Diabetes Followup0

0[] No diabetics
7[] Q1 Noninterview

[] Interview
1[] Complete interview (all persons with diabetes interviewed)
2[] Partial interview (some but not all persons with diabetes interviewed) (Explain in notes)
[] Noninterview
3[] Refusal (explain in notes)
8[] Other (explain in notes)

c. Sample person
1[] Section R (page 48) (Orofacial pain)

0[] No person 18+ in this family

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

2. Section S (page 50) (Digestive Disorders)

0[] No person 18+ in this family

[] 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[] SP mentally or physically incapable
8[] Other (Explain in notes)

3. Section T (page 56) (Diabetes Risk factors)

9[] No required
0[] No person 18+ in this family
7[] Q1 noninterview

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

8. Ending time

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

9. Interviewer identification

Name ____
Code ____