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dpo

[p.398]

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)
Polio Survivor 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

_______

[p.399]

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 (Fill II.D)
3[] SP unavailable (Fill II.D)
4[] Other - Specify (Fill II.D)
_________
_________

D. Proxy

Name _____
Relationship to SP ______

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