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[p.141]

Appendix III
Questionnaires and
Flashcards

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

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

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
Fill items 1-7a, 8 and 10 as applicable; 11, 13-17.

TYPE B

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) ______
Fill items 1-7a, 8-10 as applicable; 11, 13-17.

TYPE C

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) _____
Fill items 1-7a, 9c if marked; 13-17, send Inter-Comm

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.163]

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

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

[] 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

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.

(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.

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.

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

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