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[p.278]

U.S. Department of Commerce Bureau of the Census Acting as Collecting Agent for the U.S. Department of Health and Human Services Public Health Service
Disability Followback Survey
(NHIS Phase II)
Child Questionnaire)
Part I - Call Record

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

1[] Desired respondent (Name on label)
2[] Preferred respondent (Name in PR box on 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.279]

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
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 _____/____/19___ (Mark deceased on Cover Page)
999999 [] DK (Mark deceased on Cover Page)

[p.315]

U.S. Department of Commerce
Bureau of the Census
Acting as Collecting Agent for the
U.S. Department of Health and Human Services
Public Health Service
Disability Followback Survey
(NHIS Phase II)
Adult Questionnaire)
Part I - Call Record

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
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)
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
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.316]

Initial Screening

1. May I speak with (sample person)?

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

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
06[] Halfway house (Record new address and telephone no.)
07[] Board and Care home
08[] Developmental Center
09[] Other supervised group residence or facility
10[] Other

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 - non interview)
9[] DK/Ref (End interview - non interview)

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

__ __Month/__ __Day/__ __Year (Go to 7)

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 a hospital (End interview- noninterview)
3[] In nursing/convalescent home (End interview- noninterview)
4[] Other place (End interview- noninterview)
9[] DK(End interview- noninterview)

[p.317]

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

GENERAL INSTRUCTIONS

1. Conduct all interviews by personal visit unless the only way to get an interview is by telephone.

2. After appropriate introductions, begin all interviews with A on page 2.

3. If the sample person (or proxy) is not within your normal assignment area, call your office for instructions.

4. Make minor corrections to the sample person's address or phone number on the label. Record new addresses and/or phone numbers above.

5. If a question is refused, enter "REF" in the answer space. If the respondent does not know the answer to a question, mark the "DK" box if there is one, or enter "DK" in the answer space.

6. The following symbols and print types are used throughout the questionnaire to standardize the asking of the questions:

* Long dash (--) - Insert the appropriate words or names from the list

* Underlined italics in parentheses - Insert the specified words, name, date, etc.

* Regular type in parentheses - Either read or do not read the parenthetical, depending
on the situation and the context of the question.

*Brackets with a slash ( [ / ] ) - Choose the appropriate words or phrase for the
particular interview.

* Bold capitals - Emphasize the word(s) when reading the question

7. If interviewing a proxy, substitute the sample person's name (or appropriate pronoun) for the word "You" in the questions.