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[p.145]

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 ____
Country ____
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 ____
Country ____
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:

[] In a Special Place -- Refer to Table A in Part C of manual; then complete 10c or d
[] NOT in a Special Place (10b)

b. Access

[] Direct (10c)
[] 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. Field representative'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).

[option for 2 entries sets in the original document not presented here]

[] None
Person No. ____

Household respondent
SS. No ____
Sec. A/M ____
Sample person
Sec. B-J ____
Sec. N-X ____
AIDS ____
Family Resources ____

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 Person. No ____

[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

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 column (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 column (1)) live and eat separately from all other persons on the property?

[] Yes
[] 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?

[] Yes - Mark HU in column (5)
[] 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.

[] 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. 166]


NATIONAL HEALTH INTERVIEW SURVEY
1992 SUPPLEMENT BOOKLET
EPIDEMIOLOGY
1. Book ____ of ____ books

2. R.O. number ____

3. Sample ____

4. Control number

PSU ____
Segment ____
Serial ____

5. Family number ____

6. Field Representative's name ____

Code ____

7. Beginning time HIS-2A

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

8. Ending time HIS-2A

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

Sample Person List

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

[] Yes (List by age, oldest to youngest)
[] No (10)


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

1

Person No. ____
Age ____

Sex
1[] M
2[] F
Last name ____
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 10.

Sample Child List
10. Are there any nondeleted persons under 6 years old in this family?

[] Yes (List by age, oldest to youngest)
[] No (Section B)


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

1

Person No. ____
Age ____

Sex
1[] M
2[] F
Last name ____
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. 194]

Sample Person Number ____

Sample Person Type

1[] SP

11. Transcription from completed HIS-1

a. Education of SP (Page 42 or 43, question 2a)

00[] Never attended or kindergarten

[] Elem.
1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]
[] High:
9[]
10[]
11[]
12[]
[] College:
1(13)[]
2(14)[]
3(15)[]
4(16)[]
5(17)[]
6+(18)[]

Finish grade/year (Question 2b)

1[] Yes
2[] No

b. Main race of SP (Page 42 or 43, question 3a/b)

1[] [White]
2[] [Black]
3[] [Indian (American)]
4[] [Eskimo]
5[] [Aleut]
6[] [Chinese]
7[] [Filipino]
8[] [Hawaiian]
9[] [Korean]
10[] [Vietnamese]
11[] [Japanese]
12[] [Asian Indian]
13[] [Samoan]
14[] [Guamanian]
15[] [Other API -- Specify]
16[] [Other race -- Specify]
97[] Refused
98[] Unknown

c. Hispanic origin (Page 2 or 3, question 4e and 4f)

1[] Yes
2[] No

1[]
2[]
3[]
4[]
5[]
6[]
7[]

d. Marital status of SP (Page 46 or 47, question 7)

1[] Married -- spouse in HH
2[] Married -- spouse not in HH
3[] Widowed
4[] Divorced
5[] Separated
6[] Never married
7[] Refused
9[] Unknown

If not already completed, transcribe height and weight for the SP from page 20-21, question 5 in the HIS-1 to Section E on page 15.

Sample Child Number ____

Sample Person Type

2[] SC

12. Transcription from completed HIS-1
a. Education of SC (Page 42 or 43, question 2a)

[] Under 5
00[] Never attended or kindergarten
Elem.
1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]

Finish grade/year (Question 2b)

1[] Yes
2[] No

b. Main race of SC (Page 42 or 43, question 3a/b)

1[] [White]
2[] [Black]
3[] [Indian (American)]
4[] [Eskimo]
5[] [Aleut]
6[] [Chinese]
7[] [Filipino]
8[] [Hawaiian]
9[] [Korean]
10[] [Vietnamese]
11[] [Japanese]
12[] [Asian Indian]
13[] [Samoan]
14[] [Guamanian]
15[] [Other API -- Specify]
16[] [Other race -- Specify]
97[] Refused
98[] Unknown

c. Hispanic origin (Page 2 or 3, question 4e and 4f)

1[] Yes
2[] No

1[]
2[]
3[]
4[]
5[]
6[]
7[]

13. Transcription from completed HIS-1

a. Family income (Page 46, question 8b)

00[] A
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)

27[] $20,000 or more
28[] Less than $20,000
97[] Refused
99[] Unknown


b. Telephone number (Household page, question 11)

1[] Yes, telephone
2[] No, telephone
3[] Phone, but no number listed or number refused
9[] DK
Area code _ _ _
Number _ _ _ - _ _ _ _

14. From Cover page, item 9, of HIS-2A
a. Number of non-deleted persons 18+ years old in this family ____

From Cover page, item 10, of HIS-2A
a. Number of non-deleted children under 6 years old in this family ____

15. Response Status
Section A (Immunization)

0[] No child 0-5 in family

[] Interview
1[] Complete interview
2[] Partial interview
[] Noninterview
3[] Refusal (Explain in notes)
8[] Other (Explain in notes)

Sections B-J

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

Section L (Family Resources)

[] Interview
1[] Complete interview
2[] Partial interview
[] Noninterview
3[] Refusal (Explain in notes)
8[] Other (Explain in notes)

[p. 195]


NATIONAL HEALTH INTERVIEW SURVEY
1992 SUPPLEMENT BOOKLET
CANCER CONTROL

.
1. Book ____ of ____ books

2. R.O. Number ____

3. Sample ____

4. Control Number

PSU ____
Segment ____
Serial ____

5. Family number ____

6. Field Representative's

Name ____
Code ____

7. Beginning time HIS-2B

1[] am ____
2[] pm ____

8 Ending time HIS-2B

1[] am ____
2[] pm ____

SAMPLE PERSON LIST

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

[] Yes (List by age, oldest to youngest)
[] No (10)


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

1

Person No. ____
Age ____

Sex
1[] M
2[] F
Last name ____
First name ____
[] 1 SP
[] List No. 1

Refer to the first part of the first 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 10.

SAMPLE CHILD LIST

10. Are there any nondeleted persons under 6 years old in this family?

[] Yes (List by age, oldest to youngest)
[] No (Section N)

1

Person No. ____
Age ____
Sex
[] 1 M
[] 2 F
Last name ____
First name ____
[] 1 SC
[] List no. 1

Refer to the second part of the first sample person selection label and circle as applicable. then, mark the "SC" box in the column above for the selected sample child under 6. Next, mark the "SP" box on the HIS-1 for this person, then, go to section M.

[p. 237]

Sample Person Number ____

Sample Person Type

1[] SP

11. Transcription from completed HIS-1
a. Education of SP (Page 42 or 43, question 2a)

[] 00 Never attended or kindergarten

[] Elem:
1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]
[] High:
9[]
10[]
11[]
12[]
[] College:
1[]
2[]
3[]
4[]
5[]
6+[]

Finish grade/year (Question 2b)

1[] Yes
2[] No

b. Main race of SP (Page 42 or 43, question 3a/b)

1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]
9[]
10[]
11[]
12[]
13[]
14[]
15[]
16[]
97[] Refused
98[] Unknown

c. Hispanic origin (Page 2 or 3, question 4e and 4f)

1[] Yes
2[] No
1[]
2[]
3[]
4[]
5[]
6[]
7[]

d. Marital status of SP (Page 46 or 47, question 7)

1[] Married -- spouse in HH
2[] Married -- spouse not in HH
3[] Widowed
4[] Divorced
5[] Separated
6[] Never married
7[] Refused
9[] Unknown

If NOT already completely, transcribe height and weight for the SP from page 20-21, quesiton 5 in the HIS-1 to Section P on page 7.

Sample Child Number ____

Sample Person Type

2[] SC

12. Transcription from completed HIS-1

a. Education of SC (Page 42 or 43, question 2a)

[] Under 5
00[] Never attended or kindergarten
[] Elem
1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]

Finish grade/year (Question 2b)

1[] Yes
2[] No

b. Main race of SC (Page 42 or 43, question 3a/b)

1[]
2[]
3[]
4[]
5[]
6[]
7[]
8[]
9[]
10[]
11[]
12[]
13[]
14[]
15[]
16[]

c. Hispanic origin (Page 2 or 3, question 4e and 4f)

1[] Yes
2[] No
1[]
2[]
3[]
4[]
5[]
6[]
7[]

13. Transcription from completed HIS-1
a. Family income (Page 46, question 8b)

00[] A
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)

27[] $20,000 or more
28[] Less than $20,000
97[] Refused
99[] Unknown


b. Telephone number (Household page, question 11)

1[] Yes, telephone
2[] No telephone
3[] Phone, but no number listed or number refused
9[] DK

Area code ____

Number _ _ _ - _ _ _ _

14. From Cover page, item 9, of HIS-2B
a. Number of non-deleted persons 18+ years old in this family ____

From Cover page, item 10, of HIS-2B
a. Number of non-deleted children under 6 years old in this family ____

15. Response Status Section M (Immunization)

0[] No child 0-5 in family
[] Interview
1[] Complete interview
2[] Partial interview
[] Noninterview
3[] Refusal (Explain in notes)
8[] Other (Explain in notes)

Sections N-X

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

Section Y (AIDS)

0[] No person 18+

[] Interview
1[] Complete interview
2[] Partial interview
[] Noninterview
3[] Refusal (Explain in notes)
4[] SP temporarily absent
5[] Sp mentally or physically incapable
8[] Other (Explain in notes)

Section Z (Family Resources)

[] Interview
1[] Complete interview
2[] Partial interview
[] Noninterview
3[] Refusal (Explain in notes)
8[] Other (Explain in notes)