[p.278]
Child Questionnaire)
P
Date
Day
Beginning time
[] a.m.
[] p.m.
Results
Ending time
[] a.m.
[] p.m.
Comments
Part II - Status
02[] Partial (Explain in Notes)
Noninterview
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
2[] Personal visit
C. Respondent
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)
City
State
ZIP Code
B. Telephone (Different from label)
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?
2[] No (Skip to 6)
2. May I speak with (desired respondent)?
2[] Not available (Go to 3)
3. Will (desired respondent) [be available/ return] before (closeout date)?
2[] No (Go to 4)
4. Why will (desired respondent) not be available before (closeout date)?
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)?
2[] Address/telephone no. given (Record address and telephone no. on page 3)
6a. Do EITHER of them still live here?
2[] No (Skip to 7)
b. Who?
2[] Sample Child (Skip to 8)
7a. Did they move somewhere together?
2[] No (Skip to 8)
b. Where do (desired respondent) and (sample child) live?
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?
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)?
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?
2[] No one (End interview - noninterview)
3[] DK (End interview - noninterview)
9. On what date did (sample child) die?
999999 [] DK (Mark deceased on Cover Page)
[p.315]
Bureau of the Census
Acting as Collecting Agent for the
U.S. Department of Health and Human Services
Public Health Service
Adult Questionnaire)
P
Date
Day
Beginning time
[] a.m.
[] p.m.
Results
Ending time
[] a.m.
[] p.m.
Comments
Part II - Status
02[] Partial (Explain in Notes)
Noninterview
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
2[] Personal visit
C. Respondent
2[] Proxy
Reason for proxy
2[] SP institutionalized
3[] SP unavailable (Fill II.D)
4[] Other - Specify (Fill II.D)
_________
_________
D. Proxy
E. Field representative's name ______ Code ____
Part III- New Address
A. Address (Different from label)
City
State
ZIP Code
B. Telephone (Different from label)
Number
1[] None
7[] Refused
9[] DK number
[p.316]
Initial Screening
1. May I speak with (sample person)?
2[] Not available (Go to 2)
2. Why is (sample person) not available to be interviewed?
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)?
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?
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.
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.
2[] 69+ (Go to 4d
d. Is it possible to interview (sample person) at the [facility/present location]?
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?
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?
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?
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
Number and street
City
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK number
Number and street
City
State
ZIP Code
Telephone
Number
1[] None
7[] Refused
9[] DK number
Proxy Respondent
1[] Mark box if same address/phone as SP (Skip to A1 on page 4)
Number and street
State
ZIP Code
Telephone
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.