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[p. 143]

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. No. ____
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)

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?

[] 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

[entries in the original document repeated 6 times]

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)

[entries in the original document repeated 3 times]

[] None

Person No. ____
S.S. No. ____
Other ____

17. Record of additional contacts

[entries in the original document repeated 4 times]

Month ____
Date ____
Beginning time

a.m ____
p.m ____

Ending time

a.m ____
p.m ____

Completed Mark (X)

[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

Sheet number ____
Line number ____

Table X -- Living Quarters Determinations at Listed Address

Address of Additional Living Quarters

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.

(1)

Sheet ____
Line ____

Location of Unit

Is this a unit in a special place?

(2)

[] Yes -- Skip to column (5) and mark according to Table A in Part C of manual
[] No

Separateness and Facilities

Do the occupants (or intended occupants) of (address in column (1)) live and eat separately from all other persons on the property?

(3)

[] Yes
[] No -- Skip to column (5) and mark N

Does (address in col. (1)) have direct access from the outside or through a common hall?

(4)

[] Yes -- Mark HU in column (5)
[] No -- Mark N in column (5)

Classification

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 thsi questionnaire. Complete the appropriate segment type column for interviewing instructions.

(5)

[] N -- Stop Table X for this line
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate

[] N -- Stop Table X for this line
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate

[] N -- Stop Table X for this line
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate

Area and Block Segments

Is this unit within the segment boundaries?

(6)

[] Yes -- interview as an extra unit
[] No -- Do not interview

[] Yes -- interview as an extra unit
[] No -- Do not interview

[] Yes -- interview as an extra unit
[] No -- Do not interview

Permit Segments

Is this unit within the same structure as the original sample unit?

(7)

[] Yes -- List on first available line of listing sheet. Interveiw if in sample.
[] No -- Do not interview

[] Yes -- List on first available line of listing sheet. Interview if in sample.
[] No -- Do not interview

[] 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. 164]

Form HIS-3 (1993)

(5-1-93)

U.S. DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
U.S. PUBLIC HEALTH SERVICE

NATIONAL HEALTH INTERVIEW SURVEY

1993 SUPPLEMENT BOOKLET

Notice -- Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m). Public reporting burden for this collection of information is estimated to vary from 40 to 60 minutes per response, with an average of 50 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance Officer; ATTN: PRA; Humphrey Building, Room 721-H, 200 Independence Avenue, SW; Washington, DC 20201; and to the Office of Management and Budget, Paperwork Reduction Project (0920-0214) Washington, DC 20503.

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-3

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

8. Ending time HIS-3 (Record callbacks on HIS-1)

[] 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)

Line No.
1

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
2

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
3

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
4

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
5

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
6

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
7

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
8

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Line No.
9

Person No. ____
Age ____
Sex

1 [] M
2 [] F

Last name ____
First name ____
SP

1 []

List No. 1

Refer to the 18+ of the sample person selection label and circle as applicable. Mark (X) the "SP" box in the column above for the selected sample person 18+. THEN, go to 10.

Sample Child List

10. Are there any nondeleted persons 0-5 years old in this family?

[] Yes (List by age, oldest to youngest)
[] No (Go to Section AC on page 6)

Line No.
1

Person No. ____
Age ____
Sex

[] 1 M
[] 2 F