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[p.461]

DISABILITY FOLLOWBACK SURVEY (NHIS PHASE II) POLIO SURVIVOR QUESTIONNAIRE

Part I - CALL RECORD
Date

Month ____
Date ____

Beginning time

____ a.m.
____ p.m.

Results ____

Ending time

____ a.m.
____ p.m.

Comments ____

[p. 462]

Part II - STATUS

A. Final Status
Interview

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

Non interview

03[] SP refused (Explain in Notes)
04[] Proxy refused (Explain in Notes)
05[] Unable to contact (Explain in Notes)
06[] Unable to located (Explain in Notes)
07[] Deceased (Explain in Notes)
08[] Institutionalized, no proxy (Explain in Notes)
09[] Incapable, no proxy (Explain in Notes)
10[] Move 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 ____
Relationship to SP ____

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