[p.461]
DISABILITY FOLLOWBACK SURVEY (NHIS PHASE II) POLIO SURVIVOR QUESTIONNAIRE
Month ____
Date ____
Date ____
Beginning time
____ a.m.
____ p.m.
____ p.m.
Results ____
Ending time
____ a.m.
____ p.m.
____ p.m.
Comments ____
[p. 462]
Part II - STATUS
01[] Complete
02[] Partial (Explain in Notes)
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)
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
2[] Personal visit
C. Respondent
1[] Self
2[] Proxy
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)
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 ____
City ____
State ____
ZIP Code ____
B. Telephone (Different from label)
Area Code (____)
Number ____
1[] None
7[] Refused
9[] DK Number
Number ____
1[] None
7[] Refused
9[] DK Number