[p.137]
Appendix III. Questionnaire and Flash Cards
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
Suffix
2[] Permit
Segment
Suffix
Serial
Suffix
Check digit
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)
[] Do not ask
[] After 4-1-90 (Complete 9c when required; end interview)
[] Do not ask
[] No
b. [] Are there any other living quarters -- either occupied or vacant -- on this floor?
[] No
c. [] Is there any other building, mobile home, or trailer -- either occupied or vacant -- on this property for people to live in?
[] No
2[] RURAL
- 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?
2[] No (11)
11. CLASSIFICATION OF LIVING QUARTERS -- Mark by observation
Unit is:
2[] NOT in Group Quarters (11b)
b. Access
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.)
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
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?
Area code/number
________
b. Is there any working telephone located INSIDE your home?
2[] No
2[] No
14a. Field representative's name
Code
_____
b. Language of interview
2[] Spanish
3[] Both English and Spanish
8[] Other
15. Neighbor screening results (Mark if "S" in item 6)
1[] Screened out by neighbors
2[] Eligible per neighbor
3[] Undetermined by neighbors
Fill items 1-7a, 8 and 10 as applicable; 11, 13-17.
03 [] Temporarily absent
05 [] Other (Specify) _____
Indicate best estimate of race/ethnicity for each Type A
2[] Not Black/Hispanic
3[] Unknown
Fill items 1-7a, 8-10 as applicable; 11, 13-17.
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) ______
Fill items 1-7a, 9c if marked; 13-17, send Inter-Comm
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
___
Date
___
Beginning time
___ p.m.
Ending time
___ p.m.
Completed Mark (X)
___
18. List column numbers of persons requiring callbacks, and indicated reason(s).
[] None
S.S. No. ____
Other ____
19. Record of additional contacts
___
Date
___
Beginning time
___ p.m.
Ending time
___ 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
Is the address already listed?
[] Yes - Enter sheet and line no.: Stop Table X
Line ____
[] No - Enter address or description, then go
to column (2) or (4) depending on Seg.
____
Line ____
[] No - Enter address or description, then go
to column (2) or (4) depending on Seg.
____
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?
[] No - Do not interview
[] No - Do not interview
[] No - Do not interview
(3)
Are the additional living quarters in a Group Quarters (GQ)?
[] No - Skip to column (5)
[] No - Skip to column (5)
[] 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?
[] No - Do not interview
[] No - Do not interview
[] 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?
[] No - Not a separate unit. Stop Table X Include quarters with original unit.
[] No - Not a separate unit. Stop Table X Include quarters with original unit.
[] 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?
[] No - Not a separate unit. Stop Table X. Include quarters
with original unit.
[] No - Not a separate unit. Stop Table X. Include quarters
with original unit.
[] 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?
[] No - Enter address on listing sheet. Interview parent and extra units.
[] No - Enter address on listing sheet. Interview parent and extra units.
[] 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.