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.

First name of {subject's name} is:

Middle initial of {subject's name}:

Last name of {subject's name}:

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

(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 go to Check item RCICCI3.
Check item RCICCI3: If TELENUM = N go to RCI.096; If TELENUM = R or D go to RCI.092; Else go to RCI.091. (Note: Telephone number, TELENUM, obtained at beginning of interview)

Earlier I recorded the telephone number as {fill TELENUM}. Is this {your/your family's} telephone number?

(1) Yes (RCI.093)
(2) No (RCI.092)
(7) Refused (RCI.096)
(9) DK (RCI.096)

What is {your/your family's} telephone number? (____)_____-________

(1000000000- 9999999999) 1000000000-9999999999 (RCI.093)
(999999997) Refused (RCI.096)
(999999999) DK (RCI.096)

How is this phone number listed in the telephone directory? (What is the relationship of the person listed in the telephone directory to {fill Family Respondent}?

NAME:
RELATIONSHIP:
(7) Refused
(9) DK

{Do/Does} {you/your family} expect to move at any time in the next year?

(1) Yes (RCI.097)
(2) No (RCI.100)
(7) Refused (RCI.100)
(9) DK (RCI.100)

Approximately when do you think that will happen?
MVTIME MONTH:
YEAR:
(7) Refused
(9) DK

Where do you expect to move to?

Number and Street:
City:
State:
Zip:
Zip:
(7) Refused
(9) DK

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?

(____)_____-________
(1000000000 - 9999999999) 1000000000-9999999999
(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?

(_____)_____-__________
(1000000000-9999999999) 10000000000-9999999999
(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 RCICCI4: Go to child questionnaire, adult questionnaire, or next family.