[p.143]
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
13a. Field representative's name ____
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 indicated reason(s).
[option for 3 entries for person no, and 6 reason for callback entries for each person no. in original document not presented here]
Person No. ____
Reason(s) for callback. ____
17. Record of additional contacts
[option for 4 entries in original document not presented here]
Date ____
Beginning time
[] p.m.____
[] p.m.____
[p. 163]
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 column (1)) live and eat separately from all other persons on the property?
[] No - Skip to column (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 column (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. 164]
National Health Interview Survey : 1991 Supplement Booklet
Segment ____
Serial ____
6. Field Representative's name ____
2[] p.m. ____
2[] p.m. ____
2[] p.m. ____
2[] p.m. ____
Sample Person List
11. Are there any nondeleted persons 18+ years old in this family?
[] No (12)
[option for 9 identical entries in the original document not presented here]
1
Age ____
Sex
2[] F
First name ____
1[] SP
[] List no. 1
Refer to the first part of the sample person selection label and circle as applicable. Then, mark the "SP" box in the column above for the selected sample person 18+. Next, mark the "SP" box on the HIS-1 for this person, then, go to 12.
Sample Child List
12. Are there any nondeleted persons under 18 years old in this family?
[] No (Section A)
[option for 9 identical entries in the original document not presented here]
1
Age ____
Sex
2[] F
First name ____
1[] SC
[] List No. 2
Refer to the second part of the sample person selection label and circle as applicable. Then, mark the "SC" box in the column above for the selected sample child under 18. Next, mark the "SP" box on the HIS-1 for this person, then, go to Section A.
[p. 210]
16. From Cover page, item 11, of HIS-2
a. Number of non-deleted persons 18+ years old in this family
From Cover page, item 12, of HIS-2
b. Number of non-deleted children under 18 years old in this family
17. Response Status
Sections A, B, and E
2[] Partial interview
8[] Other (Explain in notes)
Section C (Pregnancy and Smoking)
[] Interview
2[] Partial interview
8[] Other (Explain in notes)
Section D (Child Health)
[] Interview
2[] Partial interview
8[] Other (Explain in notes)
Sections F-P
[] Interview
2[] Partial interview
8[] Other (Explain in notes)
Section Q (AIDS)
[] Interview
2[] Partial interview
4[] SP temporarily absent
5[] SP mentally or physically incapable
8[] Other (Explain in notes)
Section R (Income)
2[] Partial interview
8[] Other (Explain in notes)
HIS-3 -- Interview Mode
[] Interview
2[] SP administered, others present during interview
3[] FR administered, SP alone during interview
4[] FR administered, others present during interview
6[] SP temporarily absent
7[] SP mentally or physically incapable
8[] Other (Explain in notes)
[p. 211]
Sample Person Number ____
Sample Person Type
a. Education of SP (Page 42 or 43, question 2a)
Elem.
2[]
3[]
4[]
5[]
6[]
7[]
8[]
10[]
11[]
12[]
2(14)[]
3(15)[]
4(16)[]
5(17)[]
6+(18)[]
Finish grade/year (Question 2b)
2[] No
b. Main race of SP (Page 42 or 43, question 3a/b)
2[]
3[]
4[]
5[]
7[] Refused
8[] Unknown
c. Hispanic origin (Page 42 or 43, question 4a/b)
2[] No
0[] Multiple Hispanic
2[]
3[]
4[]
5[]
6[]
7[]
d. Marital status of SP (Page 46 or 47, question 7)
2[] Married -- spouse not in HH
3[] Widowed
4[] Divorced
5[] Separated
6[] Never married
7[] Refused
9[] Unknown
15. Transcription from completed HIS-1
a. Family income (page 46, question 8b)
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
(Transcribe from 8a if 8b blank)
28[] Less than $20,000
97[] Refused
99[] Unknown
b. Telephone number (Household page, question 11)
2[] No, telephone
3[] Phone, but no number listed or number refused
9[] DK
Area code _ _ _
Number _ _ _ - _ _ _ _