[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
Polio Survivor Questionnaire)
T
P
P
Date
Month
Day
____
Day
____
Beginning time
____
[] a.m.
[] p.m.
[] a.m.
[] p.m.
Results
_______
Ending time
____
[] a.m.
[] p.m.
[] a.m.
[] p.m.
Comments
_______
[p.399]
Part II - Status
Interview
Noninterview
01[] Complete
02[] Partial (Explain in Notes)
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)
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
2[] Personal visit
C. Respondent
1[] Self
2[] Proxy
Reason for 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)
_________
_________
2[] SP institutionalized (Fill II.D)
3[] SP unavailable (Fill II.D)
4[] Other - Specify (Fill II.D)
_________
_________
D. Proxy
Name _____
Relationship to SP ______
Relationship to SP ______
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