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[p. 288]


DISABILITY FOLLOWBACK SURVEY (NHIS PHASE II)

CHILD'S QUESTIONNAIRE

Part I -- CALL RECORD

[option for 5 entries in the original document not presented here]
Mode

[] T
[] P

Date

Month ____
Day ____

Beginning time

a.m. ____
p.m. ____

Results

____

Ending time

a.m. ____
p.m. ____

Comments

____
Part II -- STATUS
A. Final Status
Interview

01[] Complete
02[] Partial (Explain in Notes)

Noninterview

04[] Refused (Explain in Notes)
05[] Unable to contact (Explain in Notes)
06[] Unable to locate (Explain in Notes)
07[] Deceased (Explain in Notes)
10[] Moved o/s PSU, unable to phone (Explain in Notes)
11[] Other noninterview (Explain in Notes)

B. Mode

1[] Telephone
2[] Personal visit

C. Respondent

Name ____
1[] Desired respondent (Name on label)
2[] Preferred respondent (Name in PR box in page 3)
3[] Other respondent

D. Field representative's

Name ____
Code ____

Part III -- NEW ADDRESS FOR CHILD

A. Address (Different from label)

Number and street ____
City ____
State ____
ZIP Code ____

B. Telephone (Different from label)

Area code ____
Number ____
1[] None
7[] Refused
9[] DK number

[p. 289]

INITIAL SCREENING -- CHILDREN

1. I need to talk to (desired respondent) about (sample child). Do they both live here?

1[] Yes (Go to 2)
2[] No (Skip to 6)

2. May I speak with (desired respondent)?

1[] Yes (Skip to A)
2[] Not available (Go to 3)

3. Will (desired respondent) (be available/return) before (closeout date)?

1[] Yes (Arrange callback)
2[] No (Go to 4)

4. Why will (desired respondent) not be available before (closeout date)?

1[] Incapable (Skip to 8)
2[] Institutionalized (Skip to 8)
3[] Temporarily absent (Go to 5)
4[] Other (Skip to 8)

5. How can I get in contact with (desired respondent)?

1[] Not possible (Skip to 8)
2[] Address/telephone no. given (Record address and telephone no. on page 3)

6a. Do EITHER of them still live here?

1[] Yes (Go to 6b)
2[] No (Skip to 7)

b. Who?

1[] Desired respondent (Skip to 8)
2[] Sample child (Skip to 8)

7a. Did they move somewhere together?

1[] Yes (Go to 7b)
2[] No (Skip to 8)

b. Where do (desired respondent) and (sample child) live?

1[] DK (END interview-noninterview)
2[] Address/telephone no. given (Record address and telephone no. on page 3)

Read with parenthetical first.

8a. I need to speak to an adult (relative or guardian who lives with (sample child) about (sample child's) health. Who would that be?

1[] Respondent (Record preferred respondent information on page 3. Go to 8b)
2[] Other person (Record preferred respondent information on page 3. Go to 8b)
3[] SC or SC's spouse (Interview SC on DFS-2)
4[] SC died (Skip to 9)
5[] SC institutionalized (Reask 8a without first parenthetical)
6[] No one (Reask 8a without first parenthetical)
9[] DK (Skip to 8c)

b. How (are you/is this person) related to (sample child)?

1[] Mother (Continue with A or arrange callback)
2[] Father (Continue with A or arrange callback)
3[] Brother/Sister (Continue with A or arrange callback)
4[] Grandparent (Continue with A or arrange callback)
5[] Other relative (Continue with A or arrange callback)
6[] Nonrelative (Continue with A or arrange callback)
9[] DK (Continue with A or arrange callback)

c. Who would know who I should speak to about (sample child's) health?

1[] Person given -- (Record preferred respondent information on page 3)
2[] No one (End interview -- noninterview)
3[] DK (End interview -- noninterview)

9. On what date did (sample child) die?

Date of Death (Mark deceased on Cover Page)
Month ____
Day ____
Year 19____
999999[] DK

[p. 290]

INITIAL SCREENING -- Continued

NEW ADDRESS (First or only)

Name of place (If appropriate) ____
Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____
1[] None
7[] Refused
9[] DK number

Second (If appropriate) ____

Name of place (If appropriate ____
Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____
1[] None
7[] Refused
9[] DK number

PREFERRED RESPONDENT (From 8a or 8c)

Name ____
1[] Mark box if same address/phone as SC (Skip to A1 on page 5)
Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____
1[] None
7[] Refused
9[] DK number

[p. 325]


DISABILITY FOLLOWBACK SURVEY (NHIS PHASE II

ADULT'S QUESTIONNAIRE

Part I -- CALL RECORD

[option for 5 entries [1 set is from Mode to Comments] in the original document not presented here]

Mode

[] T
[] P

Date

Month ____
Day ____

Beginning time

[] a.m. ____
[] p.m. ____

Results ____

Ending time

[] a.m. ____
[] p.m. ____

Comments ____

Part II -- STATUS

A. Final Status
Interview

1[] Complete
2[] Partial (Explain in Notes)

Noninterview

03[] SP Refused (Explain in Notes)
04[] Proxy refused (Explain in Notes)
05[] Unable to contact (Explain in Notes)
06[] Unable to locate (Explain in Notes)
07[] Deceased (Explain in Notes)
08[] Institutionalized, no proxy (Explain in Notes)
09[] Incapable, no proxy (Explain in Notes)
10[] Moved o/s PSU, unable to phone (Explain in Notes)
11[] Other noninterview (Explain in Notes)

B. Mode

1[] Telephone
2[] Personal visit

C. Respondent

1[] Self
2[] Proxy

Reason for proxy

1[] SP incapable (Fill II.D)
2[] SP institutionalized (Fill II.D)
3[] SP unavailable (Fill II.D)
4[] Other -- Specify -- ____ (Fill II.D)

D. Proxy

Name ____

E. Field Representative's

Name ____
Code ____

Part III -- NEW ADDRESS

A. Address (Different from label)

Number and street ____
City ____
State ____
ZIP Code ____

B. Telephone (Different from label)

Area code ___
Number ___

1[] None
7[] Refused
9[] DK number


[p. 326]

INITIAL SCREENING

1. May I please speak with (sample person)?

1[] Yes (Go to A below)
2[] No (Go to 2)

2. Why is (sample person) not available to be interviewed?

1[] SP deceased (Skip to 6)
2[] SP moved (Skip to 4)
3[] SP temporarily absent/unavailable (Go to 3)
4[] SP incapable (Skip to 5)
5[] Other (Skip to 5)

3. Will (sample person) (return/be available) before (closeout date)?

1[] Yes (Schedule appointment)
2[] No (Go to 4)
9[] DK (Go to 4)

4a. Has (sample person) moved to a new residence or is (he/she) in a health facility, group home, or some other place?

1[] SP moved (Record new address and telephone no.)
2[] SP in health facility/group home (Go to 4b)
3[] SP in jail (Skip to 5)
4[] SP in prison (END interview -- noninterview)
5[] SP on vacation/visiting/temporarily absent (Skip to 4d)

b. What type of facility or group home is this?
Mark (X) first appropriate box.

01[] Hospital (Go to 4c)
02[] Nursing/convalescent home (Go to 4c)
03[] Retirement home (Record new address and telephone no.)
04[] Group home (Record new address and telephone no.)
05[] Supervised apartment (Record new address and telephone no.)
06[] Halfway house (Record new address and telephone no.)
07[] Board and Care home (Record new address and telephone no.)
08[] Developmental Center (Record new address and telephone no.)
09[] Other supervised group residence or facility (Record new address and telephone no.)
10[] Other (Record new address and telephone no.)

c. Refer to age on label.

1[] Under 69 (Skip to 5)
2[] 69+ (Go to 4d)

d. Is it possible to interview (sample person) at the (facility/present location)?

1[] Yes (Record address and telephone no.)
2[] No (Go to 5)

5. Since I won't be able to interview (sample person), I need to talk to the person who knows the most about (sample person's) health. Who would that be?

1[] Respondent (Go to A below)
2[] Other person (Record person's name, address, and telephone no.)
3[] No one (END interview -- noninterview)
9[] DK/Ref (END interview -- noninterview)

6. On what date did (sample person) die?

[Go to 7]
Month ____
Day ____
Year ____
999999[] DK (Go to 7)

7. Did (sample person) die at home, in a hospital, in a nursing or convalescent home, or some other place?

1[] At home (END interview -- noninterview)
2[] In hospital (END interview -- noninterview)
3[] In nursing/convalescent home (END interview -- noninterview)
4[] Other place (END interview -- noninterview)
9[] DK (END interview -- noninterview)


[p. 327]

INITIAL SCREENING -- Continued
NEW ADDRESS (First or only)

Name of place (If appropriate) ____
Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____

1[] None
7[] Refused
9[] DK number

Second (If appropriate)

Name of place (If appropriate) ____
Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____

1[] None
7[] Refused
9[] DK number

PROXY RESPONDENT

Name ____
1[] Mark box if same address/phone as SP (Skip to A1 on page 4)

Number and street ____
City ____
State ____
ZIP Code ____

Telephone

Area code ____
Number ____

1[] None
7[] Refused
9[] DK number