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[p.137]


Appendix III. Questionnaire and Flash Cards

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

National Health Interview Survey

1. RO

____

2. Sample

_____

Suffix

_____

3. Week

_____

4. Segment type

1[] Area
2[] Permit

5. Control number
PSU

_____

Segment

_____

Suffix

_____

Serial

_____

Suffix

_____

Check digit

_____

6. Screening Status

1[] S
2[] I

Listing Sheet

______
Sheet

______
Line No.

7a. What is your exact address? (Including House No., Apt. No., or other identification; county and ZIP code)

_______

City
_____

State
_____

County
_____

ZIP Code
_____

b. Is this your mailing address? (Mark box or specify if different; include county and ZIP code)
[ ] Same as 7a

_______

City
_____

State
_____

County
_____

ZIP Code
_____

c. GQ Name

_____

Sample unit No.
_____

Type code
_____

8. YEAR BUILT (Area segments only)

[] Ask (Except for group quarters, mobile houses, trailers, tents, boats and other units not in structures.)
[] Do not ask
When was this structure originally built?
[] Before 4-1-90 (Continue interview)
[] After 4-1-90 (Complete 9c when required; end interview)

9. COVERAGE QUESTIONS

[] Ask items that are marked
[] Do not ask
a. [] Are there any other living quarters -- either occupied or vacant -- in this building?
[] Yes (Fill Table X)
[] No


b. [] Are there any other living quarters -- either occupied or vacant -- on this floor?
[] Yes (Fill Table X)
[] No


c. [] Is there any other building, mobile home, or trailer -- either occupied or vacant -- on this property for people to live in?
[] Yes (Fill Table X)
[] No


10a. LAND USE

1[] URBAN (11)
2[] RURAL
- Reg. units and G.Q. units coded 92-N or 93-N in 7c - Ask item 10b
- GQ units not coded 92-N or 93-N in 7c - Mark "No" in item 10b 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?

1[] Yes (11)
2[] No (11)


11. CLASSIFICATION OF LIVING QUARTERS -- Mark by observation

a. LOCATION of unit
Unit is:
1[] In Group Quarters - Refer to GQ Table on pages 4-7 through 4-15 of the 11-8, FR Listing and Coverage Manual; then complete 11 c or d
2[] NOT in Group Quarters (11b)


b. Access
1[] Direct (11c)
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)
01[] House, apartment, flat
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


d. GROUP QUARTERS (GQ) unit (Mark one)
08[] Quarters not HU in rooming or boarding house
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[] GQ Unit not specified above -- Describe


12a. What is the telephone number here?

0[] None
Area code/number
________


b. Is there any working telephone located INSIDE your home?

1[] Yes
2[] No

13. Interview observed?

1[] Yes
2[] No

14a. Field representative's name

______

Code
_____

b. Language of interview

1[] English
2[] Spanish
3[] Both English and Spanish
8[] Other

15. Neighbor screening results (Mark if "S" in item 6)

0[] Neighbor not contacted
1[] Screened out by neighbors
2[] Eligible per neighbor
3[] Undetermined by neighbors


16. Noninterview reason

TYPE A
Fill items 1-7a, 8 and 10 as applicable; 11, 13-17.
02 [] No one home, repeated calls
03 [] Temporarily absent
05 [] Other (Specify) _____


Indicate best estimate of race/ethnicity for each Type A
1[] Black/Hispanic
2[] Not Black/Hispanic
3[] Unknown

TYPE B
Fill items 1-7a, 8-10 as applicable; 11, 13-17.
06 [] Vacant, nonseasonal
07 [] Vacant, seasonal
08 [] Occupied entirely by URE
09 [] Occupied entirely by AF members
10 [] Occupied - screened out by household
11 [] Occupied - screened out by neighbors
12 [] Unfit or to be demolished
13 [] Under construction - not ready
14 [] Converted to temporary business or storage
15 [] Unoccupied site for mobile home, trailer or tent
16 [] Permit granted - constructed not started
17 [] Other (Specify) ______
TYPE C
Fill items 1-7a, 9c if marked; 13-17, send Inter-Comm
18 [] Unused line of listing sheet
19 [] Demolished
20 [] House or trailer moved
21 [] Outside segment boundaries
22 [] Converted to permanent business or storage
23 [] Merged
24 [] Condemned
25 [] Built after April 1, 1990
26 [] Other (Specify) _____

17. Record of calls

Month
___
Date
___

Beginning time
___ a.m.
___ p.m.


Ending time
___ a.m.
___ p.m.


Completed Mark (X)
___

18. List column numbers of persons requiring callbacks, and indicated reason(s).
[] None

Person No. ___
S.S. No. ____
Other ____

19. Record of additional contacts

Month
___
Date
___

Beginning time
___ a.m.
___ p.m.


Ending time
___ a.m.
___ p.m.


Completed Person No.
___

[p.159]

Table X- Determining if an Additional Living Quarters Qualifies as an Extra Unit

ADDRESS OF ADDITIONAL LIVING QUARTERS

Check the listing sheet.

(1)
Is the address already listed?
[] Yes - Enter sheet and line no.: Stop Table X
Sheet ____
Line ____

[] No - Enter address or description, then go
to column (2) or (4) depending on Seg.
____
[] Yes - Enter sheet and line no.: Stop Table X
Sheet ____
Line ____

[] No - Enter address or description, then go
to column (2) or (4) depending on Seg.
____
[] Yes - Enter sheet and line no.: Stop Table X
Sheet ____
Line ____

[] No - Enter address or description, then go
to column (2) or (4) depending on Seg.
____

AREA SEGMENT

(2)
Are the additional living quarters within the area segment boundaries?

[] Yes - Go to column (3)
[] No - Do not interview
[] Yes - Go to column (3)
[] No - Do not interview
[] Yes - Go to column (3)
[] No - Do not interview

(3)
Are the additional living quarters in a Group Quarters (GQ)?

[] Yes - Do not interview
[] No - Skip to column (5)
[] Yes - Do not interview
[] No - Skip to column (5)
[] Yes - Do not interview
[] No - Skip to column (5)

PERMIT SEGMENT

(4)
Are there additional living quarters within the same structure and within the same space 1 occupied by the original sample unit?

[] Yes - Go to column (5)
[] No - Do not interview
[] Yes - Go to column (5)
[] No - Do not interview
[] Yes - Go to column (5)
[] No - Do not interview

1 Occupation of the same space occurs if a housing unit has been split into two or more separate housing units.

SEPARATENESS

(5)
Do the occupants or intended occupants of the additional living quarters live and eat separately from all other persons on the property?

[] Yes - Go to column (6)
[] No - Not a separate unit. Stop Table X Include quarters with original unit.
[] Yes - Go to column (6)
[] No - Not a separate unit. Stop Table X Include quarters with original unit.
[] Yes - Go to column (6)
[] No - Not a separate unit. Stop Table X Include quarters with original unit.

(6)
Do the occupants or intended occupants of the additional living quarters have direct access from the outside or through a common hall?

[] Yes - An EXTRA unit. Go to column (7)
[] No - Not a separate unit. Stop Table X. Include quarters
with original unit.
[] Yes - An EXTRA unit. Go to column (7)
[] No - Not a separate unit. Stop Table X. Include quarters
with original unit.
[] Yes - An EXTRA unit. Go to column (7)
[] No - Not a separate unit. Stop Table X. Include quarters
with original unit.

NUMBER OF EXTRA UNITS

(7)
Have you found more than 3 EXTRA units?

[] Yes - Call your office for instructions on which units to interview. 2
[] No - Enter address on listing sheet. Interview parent and extra units.
[] Yes - Call your office for instructions on which units to interview. 2
[] No - Enter address on listing sheet. Interview parent and extra units.
[] Yes - Call your office for instructions on which units to interview. 2
[] No - Enter address on listing sheet. Interview parent and extra units.

2 When your RO gas
determined which units to
interview, enter the
address on the listing
sheets and proceed with the
interviews.