What are the names of all the persons living or staying here?
Start with the name of the person, or one of the persons, who owns or rents this home.

FR: BEFORE PROCEEDING, PLEASE MAKE SURE THE REFERENCE PERSON IS NOT AN ACTIVE ARMED FORCES MEMBER

RPNAME_F FIRST NAME:____________________
RPNAME_M MIDDLE NAME:____________________
RPNAME_L LAST NAME:____________________

[If the first name and the last name are know at HHC.010 goto HHC.020; Else goto HHC.015.]

How shall I refer to [fill RPNAME_F][fill RPNAME_L] for the rest of the interview?

RPALIAS Name: ____________________ (HHC.020)

Does {FULLNAME} usually live here?

(1) Yes (HHC.040)
(2) No (HHC.030)
(7) Refused (HHC.030)
(9) DK (HHC.030)

[If HHC.020=1, then assign this person to be reference person (RP)]

Does {FULLNAME} have some other place where he/she usually lives?

(1) Yes (OTHRRP)
(2) No (HHC.040)
(7) Refused (HHC.040)
(9) DK (HHC.040)

[If HHC.020=1, then assign this person to be reference person (RP)]

Check item OTHRRP:

FR: IF THE PERSON DOES NOT USUALLY LIVE AT THIS ADDRESS AND HAS ANOTHER RESIDENCE WHERE HE/SHE DOES USUALLY LIVE, HE/SHE WILL NOT BE INCLUDED IN THIS INTERVIEW. IF THIS IS THE CASE, IDENTIFY SOME OTHER WNER/RENTER OR IF NECESSARY, SOME OTHER ADULT AS THE REFERENCE PERSON.

PRESS (P) TO ENTER SOMEONE ELSE AS THE REFERENCE PERSON. (HHC.010)

PRESS (N) IF THERE IS NO ONE ELSE IN THE HOUSEHOLD (Check Item NOMORPER)

What is {FULLNAME}'s date of birth? Month, day and year, please.

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December

DOB_M MONTH: ____________________________
DOB_BDAY DAY: ____________________________
DOB_Y_P YEAR: ____________________________

[If the year is known at HHC.050, goto Check item HHC01; Else goto HHC.080.]

Check item HHC01: Check item HHC01: Calculate AGE by subtracting reported Birth Year (before top coded to DOB_Y_P) (HHC.050) from CURRENT YEAR. If the birth month, day, and year are valid and if current date is less than birth date - subtract 1 from AGE, and goto HHC.070. If the birth month and year are valid, day is missing, and if current month is less than birth month- subtract 1 from AGE and goto HHC.070. If the birth month is missing then AGE1 = (AGE-1) and AGE2 = (AGE) and goto HHC.060.

Would you say {FULLNAME}:

(1) {AGE1} years of age? (Check item HHC02)
(2) {AGE2} years of age? (Check item HHC02)
(7) Refused (HHC.080)
(9) DK (HHC.080)
(N) Neither is correct (HHC.080)

That would make {FULLNAME} {AGE} years old. Is that correct?

(1) Yes (Check item HHC02)
(2) No (HHC.080)
(7) Refused (HHC.080)
(9) DK (HHC.080)

What is {FULLNAME}'s age?

FR: ASK IF APPROPRIATE; OTHERWISE, ENTER YOUR BEST ESTIMATE OF THE PERSON'S AGE. ENTER "0" IF UNDER 1. ENTER (C) FOR COMPUTE IF THE RESPONSE IS A RANGE OF AGES.

________________ (0-120) years old (Check Item HHC02)
(C) Compute from range (HHC.090)

FR: ENTER FIRST AND LAST NUMBERS OF THE RANGE.

RPRANGE1 First/lower _________________________________
RPRANGE2 Last/higher _________________________________

[Store (RPRANGE1 + RPRANGE2)/2 in RPAGEGES]

Check item HHC02:
If HHC.060 equals 1, store AGE1 in AGE; Else
If HHC.060 equals 2, store AGE2 in AGE; Else
If HHC.070 equals 1, set AGE equals AGE; Else store RPAGEGES in AGE.

Check item MORCK: If Person number (PX) less than 30: Append 1 more member into the roster, goto Check item SET; Else set HHC.240 equal to 2, and goto Check item MAXPER.

Check item MAXPER:

FR: A MAXIMUM OF 30 PEOPLE MAY BE INTERVIEWED IN ANY HOUSEHOLD. THE LIMIT HAS BEEN REACHED, NO QUESTIONS WILL BE ASKED FOR ANY ADDITIONAL PEOPLE. (Check Item HH05)

Check item SET: Increase Person number (PX) by 1, and goto HHC.100.

What is the name of the next person living or staying here?

NEXTNM_F FIRST NAME :____________________
NEXTNM_M MIDDLE NAME :____________________
NEXTNM_L LAST NAME :____________________

[If the first and last name are given at HHC.100, goto HHC.120; Else goto HHC.110.]

How shall I refer to {NEXTNM_F} {NEXTNM_L} for the rest of the interview?

ALIAS NAME :____________________ (HHC.120)

[If the first and last name are given at HHC.100, goto HHC.120; Else goto HHC.110.]

Does {FULLNAME} usually live here?

(1) Yes (HHC.140)
(2) No (HHC.130)
(7) Refused (HHC.130)
(9) DK (HHC.130)

Does {FULLNAME} have some other place where he/she usually lives?

(1) Yes (Check item NOLIST)
(2) No (HHC.140)
(7) Refused (HHC.140)
(9) DK (HHC.140)

Check item NOLIST:

FR: IF THE PERSON DOES NOT USUALLY LIVE AT THIS ADDRESS AND HAS ANOTHER RESIDENCE WHERE HE/SHE DOES USUALLY LIVE, HE/SHE WILL BE FLAGGED WITH "D" FOR DELETED AND NOT INCLUDED IN THIS INTERVIEW.ENTER (P) TO PROCEED TO THE NEXT PERSON. (HHC.240)

What is {FULLNAME}'s date of birth? Month, day and year, please.

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December

DOB_M MONTH: ____________________________
DOB_BDAY DAY: ____________________________
DOB_Y_P YEAR: ____________________________

[If the year is know at HHC.150, goto Check item HH15; Else goto HHC.180]

Check item HH15: Calculate AGE by subtracting reported Birth Year (HHC.150) from CURRENT YEAR. If the birth month, day, and year are valid and are known, and if current month is less than birth month - subtract 1 from AGE and goto HHC.170. If current month is the same as birth month and current day is less than birth day - subtract 1 from AGE and goto HHC.170. If the birth month is missing; then AGE1= (AGE - 1) and AGE2 = (AGE) and goto HHC.160.

Would you say {FULLNAME} is:

(1) {AGE1} years of age? (Check item HHC09)
(2) {AGE2} years of age? (Check item HHC09)
(7) Refused (HHC.180)
(9) DK (HHC.180)
(N) Neither is correct (HHC.180)

That would make {FULLNAME} {AGE} years old. Is that correct?

(1) Yes (Check item HHC09)
(2) No (AGEVER_B)
(7) Refused (HHC.180)
(9) DK (HHC.180)

[If answer equals 2, ask:]
Would you like to correct {his/her} date of birth?

(1) Yes (HHC.150)
(2) No, not remember for sure. (HHC.180)

What is {FULLNAME}'s age?

FR: ASK IF APPROPRIATE; OTHERWISE, ENTER YOUR BEST ESTIMATE OF THE PERSON'S AGE. ENTER "0" IF UNDER 1. ENTER (C) FOR COMPUTE IF THE REPONSE IS A RANGE OF AGE.

__________ (0-120) years old (Check item HHC09)
(C) Compute from range

FR: ENTER FIRST AND LAST NUMBERS OF THE RANGE.

AGEGES_1 First/lower:____________________
AGEGES_2 Last/higher:____________________

[Store (AGEGES_1 + AGEGES_2)/2 in AGEGES]

Check item HHC09:
If HHC.160 equals 1 and AGE is not equal to zero, store AGE1 in AGE; Else
If HHC.160 equals 2 and AGE is not equal to zero, store AGE2 in AGE; Else
If HHC.170 equals 1, set AGE equal to AGE; Else set AGE equal AGEGES in HHC.180.

What is {FULLNAME}'s relationship to {RP name}?

FR: HAND CARD F1.

1. Lost job or changed employers
2. Spouse/parent lost job or changed employers
3. Got divorced or separated/death of spouse or parent
4. Became ineligible because of age/left school
5. Employer stopped offering coverage
6. Cut back to part-time/became temporary employee
7. Benefits from employer/former employer ran out
8. Couldn't afford to pay premiums
9. Insurance plan raised cost of premiums
10. Insurance company refused coverage
11. Other

(2) Spouse (husband/wife) (HHC.240)
(3) Unmarried Partner (HHC.240)
(4) Child (biological/adoptive/in-law/step/foster)
(5) Child of partner (HHC.240)
(6) Grandchild (HHC.240)
(7) Parent (biological/adoptive/in-law/step/foster) (HHC.220)
(8) Brother/sister (biological/adoptive/in-law/step/ foster) (HHC.230)
(9) Grandparent(Grandmother/Grandfather) (HHC.240)
(10) Aunt/Uncle (HHC.240)
(11) Niece/Nephew (HHC.240)
(12) Other relative (HHC.240)
(13) Housemate/roommate(HHC.210)(HHC.240)
(14) Roomer/Boarder (HHC.240)
(15) Other nonrelative (HHC.240)
(16) Legal guardian (HHC.240)
(17) Ward (HHC.240)
(97) Refused (HHC.240)
(99) DK (HHC.240)

Is {FULLNAME} {RP NAME}'s biological, adoptive, step, foster {son/daughter/child}, or {son/daughter/child}-in-law?

(1) Biological {son/daughter/child} (HHC.240)
(2) Adoptive {son/daughter/child} (HHC.240)
(3) Step {son/daughter/child} (HHC.240)
(4) Foster {son/daughter/child} (HHC.240)
(5) {Son/Daughter/Child}-in-law (HHC.240)
(7) Refused (HHC.240)
(9) DK (HHC.240)

Is {FULLNAME} (PR NAME}'s biological, adoptive, step, or foster {father/mother/parent} or {father/mother/parent}-in-law?

(1) Biological {father/mother/parent} (HHC.240)
(2) Adoptive {father/mother/parent} (HHC.240)
(3) Step {father/mother/parent} (HHC.240)
(4) Foster {father/mother/parent} (HHC.240)
(5) {Father/Mother/Parent}-in-law (HHC.240)
(7) Refused (HHC.240)
(9) DK (HHC.240)

Is {FULLNAME} {RP NAME}'s full, half, adoptive, step, or foster {brother/sister} or {brother/sister}-in-law?

(1) Full {brother/sister} (HHC.240)
(2) Half {brother/sister} (HHC.240)
(3) Adoptive {brother/sister} (HHC.240)
(4) Step {brother/sister} (HHC.240)
(5) Foster {brother/sister} (HHC.240)
(6) {Brother/Sister}-in-law (HHC.240)
(7) Refused (HHC.240)
(9) DK (HHC.240)

Is anyone else living or staying here now?

(1) Yes (Check item MORCK)
(2) No (Check item NOMORPER)
(7) Refused (Check item OMORPER)
(9) DK (Check item NOMORPER)

Check item NOMORPER: If occupied entirely by persons with URE (usually live elsewhere), goto END (end of survey questionnaire); Else goto HHC.250.

Have I missed --

(1) Yes
(2) No

MISPERS1 - Any babies or small children?
MISPERS2 - Any lodgers, boarders or persons you employ who live here?
MISPERS3 - Anyone who USUALLY lives here but is now away from home traveling or in a hospital?
MISPERS4 - Anyone else staying here?

[If any of MISPERS1 - MISPERS4 is YES, goto Check item MORCK; Else goto Check item HH05]

Check item HH05: If one-person household, set HHC.260 equal to 1 and goto HHC.290; Else, goto HHC.260.

Do all the persons I have now listed live and eat together?

(1) Yes (HHC.290)
(2) No (HHC.270)
(7) Refused (HHC.290)
(9) DK (HHC.290)

Do the people who do not live and eat here have direct access from the outside or through a common hallway to a separate living quarters?

(1) Yes (HHC.280)
(2) No (HHC.290)
(7) Refused (HHC.290)
(9) DK (HHC.290)

FR: ENTER THE PERSON NUMBER OF EACH PERSON WHO DOES NOT LIVE AND EAT WITH THIS HOUSEHOLD.

[ ] TABLEX01
[ ] TABLEX02
[ ] TABLEX03
[ ] TABLEX04
[ ] TABLEX05
[ ] TABLEX06
[ ] TABLEX07
[ ] TABLEX08
[ ] TABLEX09
[ ] TABLEX10

[Delete the person(s) whose person number is listed in HHC.280. If the deleted person is a reference person, set the next non-deleted person as reference person]

Do members of any other household on the property live and eat with members of this household?

(1) Yes (Check item ADDOTH)
(2) No (Check item P_HHRESP)
(7) Refused (Check item P_HHRESP)
(9) DK (Check item P_HHRESP)

Check item ADDOTH:

FR: THIS UNIT (HOUSEHOLD) INCLUDES THE SPACE OCCUPIED BY ALL PERSONS WHO LIVE AND EAT TOGETHER. ENTER (P) TO ADD THE ADDITIONAL PERSON(S) TO THE HOUSEHOLD ROSTER (HHC.240).

Check item P_HHRESP: If one-person household, set HHC.300 to 01, then goto Check item HHC10; Else goto HHC.300.

FR: ASK IF NECESSARY: With whom am I speaking? IF MORE THAN ONE, ENTER THE NUMBER OF THE ONE YOU CONSIDER TO BE THE MAIN RESPONDENT.

HHRESP Enter Person's # [ ]

Check item HHC07: Go over all household members: For each a non-deleted person, goto Check item HHC10; at end goto Check item HHC15.

Check item HHC10: If AGE is between 16-64 goto HHC.310; Else, goto HHC.330.

{Are/Is} {you/subject's name} now on full-time active duty with the armed forces?

(1) Yes (HHC.320)
(2) No (HHC.330)
(7) Refused (HHC.330)
(9) DK (HHC.330)

Where {do/does} {you/subject's name} usually live and sleep-- here or somewhere else?

(1) Here, living at home
(2) Somewhere else, not living
(7) Refused
(9) DK at home

Check item HHC11: If HHC.320 equals to 2, delete this person from the household, then goto HHC.310 for next person; Else if the person is a reference person and no answer in HHC.410, delete the reference person flag, goto HHC.330.

What race {do/does} {you/subject'same} consider {yourself/himself/herself} to be?

FR: HAND FLASHCARD R.

1. White
2. Black / African American
3. Indian (American)
4. Eskimo
5. Aleut
6. Chinese
7. Filipino
8. Hawaiian
9. Korean
10. Vietnamese
11. Japanese
12. Asian Indian
13. Samoan
14. Guamanian
15. Other Asian/Pacific Islander

(1) White
(2) Black/African American
(3) Indian (American)
(4) Eskimo
(5) Aleut
(6) Chinese
(7) Filipino
(8) Hawaiian
(9) Korean
(10) Vietnamese
(11) Japanese
(12) Asian Indian
(13) Samoan
(14) Guamanian
(15) Other Asian, Pacific Islander (HHC.370)
(16) Other (HHC.370)
(97) Refused
(99) DK

RACE1
RACE2
RACE3
RACE4
RACE5

(Goto HHC.380)

FR: SPECIFY THE OTHER API OR RACE.

RACSPY1 Other API: ____________________ (HHC.360)

FR: SPECIFY THE OTHER RACE.

RACSPY2 Other Race: ____________________ (HHC.360)

Check item HHC13: If anyone in RACE1 to RACE5 is 2 set PSCREENIN to 1. If more than 1 entry in RACE1 to RACE5 goto MULTRAC.

Which one of these groups, that is (FR: READ GROUPS) would you say BEST represents {your/subject's name's} race?

(01-16) Race
(97)Refused
(99)DK

Check item HHC14: Loop to Check item HHC07 for the next person.

Check item HHC15: If SCR_STAT=2 (interviewed household), SCR_STAT=1 (screened household) or where anyone is Black (PSCREENIN=1) or Hispanic, goto HHC.390. If SCR_STAT=1 and no one in the household is Black or Hispanic goto EXIT.

Check item EXIT: Set outcome code and goto CLOSE2 in the BACK section of the survey questionnaire for the preparation of closing the interview.

FR: ARE ALL LISTED PERSONS FLAGGED WITH A "D" OR "A"?

(1) Yes (CLOSE2)
(2) No (HHC.400)

[CLOSE2 is in the BACK section of the survey instrument for the preparation of closing the interview]

FR: ARE ANY CORRECTIONS NEEDED IN THE HOUSEHOLD ROSTER? FOR EXAMPLE, HAS THE WRONG PERSON BEEN DESIGNATED AS THE REFERENCE PERSON AND ARE ANY RELATIONSHIPS TO THE REFERENCE PERSON INCORRECT?

(1) Yes, change Reference Person (HHC.410)
(2) Yes, change Relationships (HHC.200 for all household members)
(3) No, corrections/No more corrections (HHC.420)

FR: SELECT NEW REFERENCE PERSON FROM LIST BELOW.

UPDATE3 [ ] PERSON NUMBER OF NEW REFERENCE PERSON.

(Goto HHC.200 for all household members)

FR: PROBE AS NECESSARY TO ESTABLISH RELATIONSHIP OF PERSON(S) NOT RELATED TO THE REFERENCE PERSON. THE REFERENCE PERSON'S FAMILY NUMBER IS "1"; THE FIRST UNRELATED PERSON OR FAMILY IS NUMBER "2"; THE SECOND UNRELATED PERSON OR FAMILY IS NUMBER "3", AND SO FORTH.

DO NEW FAMILY NUMBERS NEED TO BE ASSIGNED TO ANY HOUSEHOLD MEMBER?

(1) Yes, additional numbers (HHC.430)
(2) No, all are in family "2" (Check item HHC23)
(P) Proceed, no more corrections (Check Item HHC23)

FR: SELECT PERSON NUMBER BELOW AND CHANGE FAMILY NUMBER FOR FAMILY #3, #4, ...

Person Number
[ ] FAMNUM01
[ ] FAMNUM02
[ ] FAMNUM03
[ ] FAMNUM04
[ ] FAMNUM05
[ ] FAMNUM06
[ ] FAMNUM07
[ ] FAMNUM08
[ ] FAMNUM09
[ ] FAMNUM10

Family Number
[ ] FAMNUM11
[ ] FAMNUM12
[ ] FAMNUM13
[ ] FAMNUM14
[ ] FAMNUM15
[ ] FAMNUM16
[ ] FAMNUM17
[ ] FAMNUM18
[ ] FAMNUM19
[ ] FAMNUM20

Check item HHC23: Starting with family #1, complete the relationship among non-deleted family members in each family from HHC.440 to HHC.570.

[If Reference person's spouse or partner is male and has child(ren) then goto HHC.440]

[If Reference person's spouse or partner is female and has child(ren) then goto HHC.450]

[After completing data (HHC.440 - HHC.570) for every member of household, verify household member's NAME, AGE, SEX, NATIONAL ORIGIN, and RACE with the respondent again, make corrections if necessary; Else go to Check item EMANCIP.]

I recorded that {father's fullname} is the father of {child's fullname}. Is {child's fullname} his biological, adoptive, step, foster child, or {son/daughter}-in-law?

(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5) {son/daughter}-in-law
(7) Refused
(9) DK
(Goto HHC25)

I recorded that {mother's fullname) is the mother of {child's fullname}. Is {child's fullname} her biological, adoptive, step, foster child, or {son/daughter}-in-law?

(1) Biological child
(2) Adoptive child
(3) Step child
(4) Foster child
(5) {son/daughter}-in-law
(7) Refused
(9) DK

Check item HHC25: If AGE greater than or equal to 14 goto HHC.460; Else goto HHC.530.

{Are/Is} {you/subject's name} now married, widowed, divorced, separated, never married or living with a partner?

(1) Married (HHC.470)
(2) Widowed (Check item)
(3) Divorced (Check item)
(4) Separated (Check item)
(5) Never Married (Check item)
(6) Living with a partner (HHC.490)
(7) Refused (HHC.530)
(9) DK (HHC.530)

[For HHC.460, if one person goto HHC26; Else goto HHC.530.]

Is {subject name's} spouse living in the household?

FR: ASK OR VERIFY.

(1) Yes (HHC.480)
(2) No (HHC.530)
(7) Refused (HHC.530)
(9) DK (HHC.530)

FR: PROBE AS NECESSARY AND ENTER THE PERSON NUMBER OF THE SPOUSE.

(01-30) Person number
(97) Refused
(99) DK

(Goto HHC.530)

{Have/Has} {you/subject's name} ever been married?

(1) Yes (HHC.500)
(2) No (HHC.510)
(7) Refused (HHC.510)
(9) DK (HHC.510)

What is {your/subject's name's} current legal marital status?

(1) Married (HHC.510)
(2) Widowed (HHC.510)
(3) Divorced (HHC.510)
(4) Separated (HHC.510)
(7) Refused (HHC.510)
(9) DK (HHC.510)

FR: PROBE AS NECESSARY AND ENTER THE PERSON NUMBER OF THE COHABITING PARTNER.

(01-30) Person number
(97) Refused
(99) DK

[If person number enered is a deleted person, or Don't Know or Refused a person number, goto HHC.520; Else goto HHC.530.]

FR: CHECK THAT THE PERSON NUMBER IS CORRECT.

(1) Correct, proceed to next question (HHC.530)
(2) Incorrect, change answer (HHC.510)

Is {subject's name's} mother a household member?

FR: ENTER THE PERSON NUMBER OF MOTHER.

(00) No mother in the family (HHC.550)
(97) Refused (HHC.550)
(01-30) Person number (HHC.540)
(99) DK (HHC.550)
(G) No Parent in Household; Has legal guardian. (HHC.570)

{Are/Is} {you/mother name}{subject's name's} biological, adoptive, step, foster mother, or mother-in-law?

(1) Biological mother
(2) Adoptive mother
(3) Step mother
(4) Foster mother
(5) Mother-in-law
(7) Refused
(9) DK

Is {subject's name's} father a household member?

FR: ENTER THE PERSON NUMBER OF FATHER.

(00) No father in the family (Check item HHC26)
(01-30) Person number (HHC.560)
(G) No Parent in Household; Has legal guardian. (HHC.570)
(97) Refused (Check item HHC26)
(99) DK (Check item HHC26)

{Are/Is} {you/father's name}{subject's name} biological, adoptive, step, foster father, or father-in-law?

(1) Biological father
(2) Adoptive father
(3) Step father
(4) Foster father
(5) father-in-law
(7) Refused
(9) DK

FR: PROBE AS NECESSARY AND ENTER THE PERSON OF (SUBJECT'S NAME'S) GUARDIAN. IF THE GUARDIAN IS NOT A HOUSEHOLD NUMBER, ENTER ?".

(01-30) Person number
(97) Refused
(99) DK

Check item HHC26: Goto Check item HHC23.

Check item EMANCIP: Cycle all families, in each family if a non-deleted person is 14-17 years old, living alone (single), married, or living with a partner, set this person as Emancipated minor (CSTATFLG=4), goto Check item SASEL.

Check item SASEL: If one or more eligible adult (non-deleted person, age 18 and older and not in the Armed Forces), randomly select one adult in each family as Sample Adult.

[If any children (non-deleted person, age, less than 18 years old and not an Emancipated minor), goto Check item SCSEL; else goto HHC.730]

Check item SCSEL: Randomly select one eligible child as sample child, then goto HHC.730.

Who in the family would you say knows about the health of all the family members?

(01-30) Person number
(97) Refused
(99) DK

(01-30) Person number
(97) Refused
(99) DK

(01-30) Person number
(97) Refused
(99) DK

[If a sample child is selected, then goto HHC.740; Else goto next section]

We select one child in each family for additional health questions. In this family that is {sample child's name}. Who in the family would you say knows about the health of {sample child's name}?

FR: ENTER UP TO THREE PERSON NUMBERS. DO NOT ENTER THE SAMPLE CHILD'S NUMBER.

(01-30) Person number
(97) Refused
(99) DK

(01-30) Person number
(97) Refused
(99) DK

(01-30) Person number
(97) Refused
(99) DK

(01-30) Person number
(97) Refused
(99) DK

[Goto next section -- Family Health Status and Limitation of Activities]

FR: VERIFY OR ASK IF NAME IS MISSING OR WAS REFUSED OR NOT KNOWN. ENTER (D) OR (R) FOR ANY PARTS OF NAME REFUSED OR NOT KNOWN. IF THERE IS NO MIDDLE INITIAL, LEAVE BLANK.

NAMVER_F First name of {subject's name} is: _______________________
NAMVER_M Middle initial of {subject's name}: ______________________
NAMVER_L Last name of {subject's name}: _________________________

FR: MARK FIRST CATEGORY THAT APPLIES FOR {subject's name}.

(1) Present for all questions
(2) Present for some questions
(3) Not present

Does {subject's name} usually go by another first name?

(1) Yes (RCI.040)
(2) No (Check item RCICCI1)
(7) Refused (Check item RCICCI1)
(9) DK (Check item RCICCI1)

What is this other first name?

Name: _______________________________________
(7) Refused
(9) DK

Check item RCICCI1: If HHC.040 equal 1, 7, or 9 go to RCI.060; Else
If HHC.040 equal 2 and HHC.460 equal 5 or AGE less than 14 go to RCI.060; Else
If HHC.040 equal 2 and HHC.460 equal 6 and HHC.490 not equal 1 go to RCI.060;
Else go to RCI.050.

What is {subject's name}'s maiden name?

(S) Same as current last name (displayed above)
(7) Refused
(9) DK

What is {subject's name}'s FATHER'S last name?

(S) Same as current last name (displayed above)
(7) Refused
(9) DK

FR: READ TO RESPONDENT(S):
We also need {subject's name}'s Social Security Number. The National Center for Health Statistics will use {subject's name}'s Social Security Number to conduct health-related research by linking your survey data with vital statistics and other records. We may also use it if we need to recontact you or your family. Except for these purposes, the National Center for Health Statistics will not release {subject's name}'s SSN to anyone, including any government agency. Providing this information is voluntary and is collected under the authority of the Public Health Service Act. There will be no effect on {subject's name}'s benefits if you do not provide it.

FR: READ IF NECESSARY:
The Public Health Service Act is title 42, United States Code, section 242k.

What is {subject's name}'s Social Security Number?
Social Security Number : _____ - ____ -______ (RCI.080)
(999999997) Refused (RCI.075)
(999999999) DK (RCI.075)

FR: DO NOT READ TO RESPONDENTS(S)

Have you convinced the respondent to give you the SSN?

(1) Yes (RCI.060)
(2) No (Check item RCICCI2)

FR: ENTER HOW SOCIAL SECURITY NUMBER WAS REPORTED.

(1) from Memory
(2) from Records

FR: SELECT ONE CATEGORY BELOW TO INDICATE REPORTING OF SOCIAL SECURITY NUMBER

(1) Self - in person
(2) Self - telephone
(3) Proxy - in person
(4) Proxy - telephone

Check item RCICCI2: Return to RCI.020 for next non-deleted person until the family roster is exhausted. When family roster is exhausted: If family respondent, go to RCI.100; Else goto Check item RCICCI3.

FR: READ TO RESPONDENT:
The United States Public Health Service may wish to contact you again to obtain additional health related information. Please give me the names, addresses, and telephone numbers of TWO relatives or friends who would know where you could be reached in case we have trouble reaching you. (Please give me the names of persons not currently living in the household.)

FIRST CONTACT PERSON'S NAME:

CP1NAME1 First Name: ________________________________________
CP1NAME2 Middle Initial: _______________________________________
CP1NAME3 Last Name: _________________________________________

What is this person's address?

CP1ADDR1 Number and street: ____________________________________
CP1ADDR2 City: ____________________
CP1ADDR3 State: ____
CP1ADDR4 Zip: _______ -
CP1ADDR5 Zip: ______

What is this person's telephone number, beginning with the area code?

( _____ ) _____ - ______
(9999999996) Does not have a telephone
(9999999997) Refused
(9999999999) DK

What is the relationship of this contact person to [fill CP1NAME]?

(1) Spouse (Husband or wife)/ex-spouse not living in HH
(2) Unmarried partner not living in HH
(3) Child
(4) Grandchild
(5) Parent (mother or father)
(6) Brother or sister
(7) Grandparent
(8) Other relative
(9) Legal Guardian
(10) Friend
(11) Co-worker
(12) Neighbor
(13) Other
(97) Refused
(99) DK

FR: READ TO RESPONDENT:
Please give us the name, address, and telephone number of the second relative or friend who would also know where you could be reached in case we have trouble reaching you. Again, this should be someone who is not currently living in the household.

SECOND CONTACT PERSON'S NAME:

CP2NAME1 First Name: _________________________________________
CP2NAME2 Middle Initial: _______________________________________
CP2NAME3 Last Name: _________________________________________

What is this person's address?

CP2ADDR1 Number and street: ____________________________________
CP2ADDR2 City: ____________________
CP2ADDR3 State: ____
CP2ADDR4 Zip: _______ -
CP2ADDR5 Zip: ______

What is this person's telephone number, beginning with the area code?

( _____ ) _____ - ______
(9999999996) Does not have a telephone
(9999999997) Refused
(9999999999) DK

What is the relationship of this contact person to [fill CP2NAME]?

(1) Spouse (Husband or wife)/ex-spouse not living in HH
(2) Unmarried partner not living in HH
(3) Child
(4) Grandchild
(5) Parent (mother or father)
(6) Brother or sister
(7) Grandparent
(8) Other relative
(9) Legal Guardian
(10) Friend
(11) Co-worker
(12) Neighbor
(13) Other
(97) Refused
(99) DK

Check item RCICCI3: Goto child section, adult section, or next family.