[p.142]
Appendix III. Questionnaire and Flash Cards
Bureau of the Census
Acting as Collecting Agent for the
U.S. Department of Health and Human Services
Public Health Service
National Health Interview Survey
[] Permit
[] Block
Segment ____
Serial ____
LISTING SHEET
Line No. ____
State ____
County ____
ZIP Code ____
b. Is this your mailing address? (Mark box or specify if different; include county and ZIP code)
City ____
State ____
County ____
ZIP Code ____
c. Special place name
Type code ____
AREA AND BLOCK SEGMENTS
[] Do not ask
When was this structure originally built?
[] After 4-1-80 (Complete item 8c when required; end interview)
[] Do not ask
[] No
[] No
[] No
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?
2[] No (10)
10. CLASSIFICATION OF LIVING QUARTERS -- Mark by observation
a. LOCATION of unit
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
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)
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
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
GO TO HOUSEHOLD COMPOSITION PAGE
11a. What is the telephone number here?
Area code _ _ _
Number _ _ _ _ _ _ _
b. Is there any working telephone located INSIDE your home?
2[] No
2[] No
13a. Field representative's name ____
Code ____
b. Language of interview
2[] Spanish
3[] Both English and Spanish
8[] Other
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]
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]
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]
Date ____
p.m ____
p.m ____
16. List column numbers of persons requiring callbacks, and indicated reason(s)
Person No. ____
S.S. No. ____
Other ____
17. Record of additional contacts
Date ____
p.m ____
p.m ____
[p. 162]
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
Line number ____
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.
Line ____
Line ____
Line ____
Location of Unit
2. Is this a unit in a special place?
[] No
[] No
[] No
Separateness and Facilities
3. Do the occupants (or intended occupants) or (address in column (1)) live and eat separately from all other persons on the property?
[] No -- Skip to column (5) and mark N
[] No -- Skip to column (5) and mark N
[] 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?
[] No -- Mark N in column (5)
[] No -- Mark N 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.
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate
[] HU -- Fill column (6) or (7), as appropriate
[] OT -- Fill column (6) or (7), as appropriate
Area and Block Segments
6. Is this unit within the segment boundaries?
[] No -- Do not interview
[] No -- Do not interview
[] No -- Do not interview
Permit Segments
7. Is this unit within the same structure as the original sample unit?
[] No -- Do not interview
[] No -- Do not interview
[] No -- Do not interview
Note: Be sure to continue interview for original unit after completing Table X for all lines.
[p. 163]
NATIONAL HEALTH INTERVIEW SURVEY
1994 SUPPLEMENT BOOKLET
I. IMMUNIZATION. II. DISABILITY
Segment ____
Serial ____
6. Field Representative's name ____
2[] p.m ____
2[] p.m ____
SAMPLE CHILD LIST
ITEM I1
Are there any nondeleted persons under 6 years old in this family?
[] No (Section II, page 12)
[option for 9 in the original document not presented here]
1. Line no.
Age ____
Sex
2[] F
First name ____
SC
Refer to sample child section label and circle as applicable. THEN, mark (X) the "SC" box in the column above for the selected sample child under 6.
ITEM I2A
Are there any non-selected 2 year olds in the above list?
[] No (12B)
Are there any non-selected 1 year olds in the above list?
[] No (Section 1)
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within:
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
If month of interview is:
Mark (X) box in "19-35 months" column if child's date of birth is within :
Complete final status on Back Cover:
[p. 164]
Item X1
Enter conditions reported in the disability supplement in X1. If insufficient space to enter multiple sources, continue in a footnote. [Option for 5 entries in the original document not presented here]
B[] ____
C[] ____
D[] ____
E[] ____
F[] ____
G[] ____
Item X2
Indicate ADL Limitations in X2
[] Spec. Equip
[] Difficulty/ Doesn't do
[] Spec. Equip
[] Difficulty/ Doesn't do
[] Spec. Equip
[] Difficulty/ Doesn't do
[] Spec. Equip
[] Difficulty/ Doesn't do
[] Spec. Equip
[] Difficulty/ Doesn't do
[] Spec. Equip
[] Difficulty/ Doesn't do
Indicate IADL Limitations in X3
[] Difficulty/Doesn't do
[] Difficulty/Doesn't do
[] Difficulty/Doesn't do
[] Difficulty/Doesn't do
[] Difficulty/Doesn't do
[] Difficulty/Doesn't do