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

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

NAME_FNA FIRST NAME: __________________________________
NAME_MNA MIDDLE NAME: __________________________________
NAME_LNA LAST NAME: __________________________________

Check item: If NAME_FNA or NAME_LNA is (D,R) goto HHC.015; Else goto HHC.020.

How shall I refer to {you/this person} for the rest of the interview?

ALIAS Name: _____________________________________

{Do/Does} {you/name} usually live here?

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

{Do/Does} {you/name} have some other place where you/he/she usually lives?

(1) Yes (HHC.035)
(2) No (HHC.040)
(7) Refused (HHC.040)
(9) DK (HHC.040)

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.

FR: ASK IF NECESSARY.
(Is anyone else living or staying here now?)

(1) Yes (HHCCCI1)
(2) No (HHC.050)
(7) Refused (HHC.050)
(9) DK (HHC.050)

FR: READ FIRST TIME ONLY:
I have listed living here (READ NAMES).

(1) Yes
(2) No
(7) Refused
(9) Don't know

Have I missed -

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 HHCCCI1. If MISPERS1 -MISPERS4 are (no, DK, refused); go to HHCCCI2.

Check item HHCCCI1: If total number of household members is less than 30 goto HHC.010; Else goto HHC.055.

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 HHCCCI2: If all the household members are flagged with "D" (=URE or unusual residence elsewhere), then OUTCOME=225 and ACTION=31, goto END; Else goto HHC.060.

Do all the persons I have listed live AND eat together?
FR: READ NAMES IF NECESSARY.

(1) Yes (HHC.090)
(2) No (HHC.070)
(7) Refused (HHC.090)
(9) Don't Know (HHC.090)

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.080)
(2) No (HHC.090)
(7) Refused (HHC.090)
(9) Don't know (HHC.090)

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

[ ] TABX_1
[ ] TABX_2
[ ] TABX_3
[ ] TABX_4
[ ] TABX_5
[ ] TABX_6
[ ] TABX_7
[ ] TABX_8
[ ] TABX_9
[ ] TABX_10

(Go to HHC.090)

Check item HHC04: Cycle the roster, for each person number entered in TABX_1 to TABX_10: Set HHSTAT eq [D]At end, goto OTHLIV.

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

(1) Yes (HHC.095)
(2) No (HHC.100)
(7) Refused (HHC.100)
(9) Don't know (HHC.100)

FR: THIS UNIT (HOUSEHOLD) INCLUDES THE SPACE OCCUPIED BY ALL PERSONS WHO LIVE AND EAT TOGETHER.

(Goto HHC.040)

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

HHRESP [Enter Person #]

Check item HHCCCI3: Cycle the roster and ask questions on SEX, AGE, DOB, ETHNICITY, RACE, and NOWAF of all un-deleted household members. At end goto HHCCCI6

FR: ASK IF NOT APPARENT:
IF DON'T KNOW OR REFUSED ENTER YOUR BEST GUESS
{Are/Is} {you/name} male or female?

(1) Male
(2) Female

What is {your/name} age and date of birth? Please give month, day, and year for the date of
birth.

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't know

AGEDOB_1[] Age/ Number
AGEDOB_2[] Time Period

(1) Day(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)

Date of Birth:

DOB_MMONTH: ______________________
DOB_BDAY DAY: ______________________
DOB_Y_PYEAR: ______________________

Check item AGECAL: AGE1 takes information entered in AGEDOB1 and AGEDOB2 and calculates an age. AGE2 takes the date-of-birth information entered in AGEDOB and calculates an age. AGE3 = current year - birth year -1, AGE4 = AGE3 + 1. If not enough DOB information was given to calculate an age, "D" will be assigned to AGE2.
Check item AGECK: AGECK compares the two ages calculated in AGE1 and AGE2. AGE1 and AGE2 will either contain an age, or "D" if an age could not be calculated.
If AGE1 eq [D] and AGE2 ne [D], set AGE = AGE2, goto HHC.170
If AGE1 eq [D] and AGE2 eq [D], and AGE3 eq blank, goto HHC.150
If AGE1 eq [D] and AGE2 eq [D], and AGE3 ne lt or gt, goto HHC.130
If AGE1 ne [D] and AGE2 ne [D], and AGE1 eq AGE2, goto HHC.170
If AGE1 ne [D] and AGE2 ne [D], and AGE1 ne AGE2, and DOBVER eq lt or gt, goto
HHC.124
If AGE1 ne [D]and AGE2 ne [D], and AGE1 ne AGE2 and DOBVER ne lt or gt ; set
AGE=AGE2, goto HHC.170
If AGE1 ne [D] and AGE2 = [D], and (AGE1 = AGE3 or AGE1 = AGE4); set AGE =
AGE1; goto HHC.170
If AGE1 ne AGE3 and AGE1 ne AGE4 and birth year eq blank, goto HHC.130
If AGE1 ne AGE3 and AGE1 ne AGE4 and birth year ne lt or gt ; set AGE = AGE1, goto HHC.170

There is a difference between the age the computer calculated from {your/name's} date-of-birth and the age that you gave me. I recorded {your/name's} date-of-birth as {DOB_M/DOB_BDAY/DOB_Y_P}. Is that {your/name's} correct date-of-birth?

(1) Yes (HHC.170)
(2) No (HHC.128)
(7) Refused (HHC.170)
(9) Don't know (HHC.170)

FR: OLD DATE of BIRTH = {DOB_M/DOB_BDAY/DOB_Y_P}
ASK IF NECESSARY:

What is {your/name's} correct date-of-birth?

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December
(97) Refused
(99) Don't know

DOB_MMONTH: ______________
DOB_BDAY DAY: ______________
DOB_Y_PYEAR: ______________

[If valid birthdate is given, update AGE accordingly. If [D,R] is given for the birthdate, set AGE eq AGE1, goto HHC.170]

{Are you/Would you say} {your/name's} is
[If AGE3 eq (0)]

(1) Less than 1 year old? (HHC.170)

[else]
(1) {AGE3} year(s) old? (HHC.170)
(2) {AGE4} year(s) old? (HHC.170)
(N) Neither is correct (HHC.150)
(7) Refused (HHC.150)
(9) DK (HHC.150)

[If answer is (1, 2); update AGE accordingly, goto HHC.170]

FR: IF THE RESPONDENT DOES NOT KNOW THE AGE, ENTER YOUR BEST ESTIMATE OF THE PERSON'S AGE. ENTER (C) FOR COMPUTE IF THE RESPONSE IS A RANGE OF AGES.

What is your best guess of {your/name's} age?

AGEGES11 [] Number

(97) Refused (HHC.152)
(99) DK (HHC.152)

AGEGES12 []Time Period

(3) Month(s) (Check item)
(4) Year(s) (Check item)
(C) Compute from range (HHC.160)
(7) Refused (HHC.152)
(9) Don't Know (HHC.152)

Check item: If AGEGES12 is (3) then AGE eq (NUM/12); If AGEGES12 is (4) then AGE eq (NUM). If DOB_Y_P eq (D, R); set BYY1 eq (current year-AGE1-1) and BYY2 eq (current year- AGE) goto HHC.165; If DOB_Y_P ne (D, R); set AGE eq (AGE1), goto HHC.170. If AGEGES12 eq (D, R), goto HHC.152.

Certain sections of this interview depend on knowing if a person is 18 years old or older. Could you please tell me if {you/name} {are/is} at least 18 years old?

(1) Less than 18 (HHC.154)
(2) 18 or older (HHC.154)
(7) Refused (HHC.156)
(9) DK (HHC.156)

FR: ENTER YOUR BEST ESTIMATE OF {your/name's} AGE.
ENTER "0" IF LESS THAN 1 YEAR OLD.

LESS18 Age: ________________

(Goto HHC.170)

FR: ENTER YOUR BEST ESTIMATE OF {your/name's} AGE.

Age:____________(Enter age 18 or greater)

(Goto HHC.170)

FR: ENTER FIRST AND LAST AGES OF THE RANGE.
First/lower:

AGERNG_1 [] Number
AGERNG_3 [] Time period

Last/higher:

AGERNG_2 [] Number
AGERNG_4 [] Time period

(Goto HHC.170)
[Set AGE = (AGERNG_1 + AGERNG_2) /2]

Would you say that {you/name} {were/was} born in:

(1) [fill with 4-digit BYY1]
(2) [fill with 4-digit BYY2]
(N) Neither is correct
(7) Refused
(9) Don't Know

FR: SHOW FLASHCARD H1.

Do any of these groups represent (you/name's) national origin or ancestry?
FR: READ IF NECESSARY:

Puerto Rican
Cuban
Cuban American
Mexican/Mexicano
Mexican American
Chicano
Hispanic
Other Latin American
Other Spanish or Hispanic

(Where did {your/name's} ancestors come from?)

1. Puerto Rican
2. Cuban
3. Cuban American
4. Mexican/Mexicano
5. Mexican American
6. Chicano
7. Hispanic
8. Other Latin American
9. Other Spanish or Hispanic

(1) Yes (HHC.180)
(2) No (HHC.200)
(7) Refused (HHC.200)
(9) Don't know (HHC.200)

Please give me the number of the group.

FR: IF A NONHISPANIC GROUP IS NAMED, PRESS "F1" TO RETURN TO
NATOR AND CHANGE THE ANSWER FROM "YES" TO "NO".

ENTER ALL THAT APPLY. ENTER (N) FOR NO MORE.

(1) Puerto Rican (HHC.200)
(2) Cuban (HHC.200)
(3) Cuban American(HHC.200)
(4) Mexican/Mexicano (HHC.200)
(5) Mexican American (HHC.200)
(6) Chicano (HHC.200)
(7) Hispanic (HHC.200)
(8) Other Latin American (HHC.190)
(9) Other Spanish or Hispanic (HHC.190)
(97) Refused (HHC.200)
(99) Don't know (HHC.200)

FR: SPECIFY THE OTHER LATIN AMERICAN OR OTHER SPANISH OR
HISPANIC

SPECH_1 Other Latin American: __________________________
SPECH_2 Other Spanish or Hispanic: _______________________

FR: SHOW FLASHCARD H2

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

What race {do/does} {you/name} consider {yourself/himself/herself} to be?

(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.210)
(16) Other (HHC.215)
(97) Refused (HHCCCI4)
(99) Don't know (HHCCCI4)

[ ] RACE
[ ] RACE2
[ ] RACE3
[ ] RACE4
[ ] RACE5

(Go to HHCCCI4)

FR: SPECIFY THE OTHER API RACE

RACSPY1 Other Asian, Pacific Islander: _________________________

(Goto HHCCCI4)

FR: SPECIFY THE OTHER RACE

RACSPY2 Other Race: ___________________________

(Goto HHCCCI4)
Check item HHCCCI4: If multiple entries in RACE goto HHC.220; Else goto HHCCCI5.

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

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

Check item HHCCCI5: If a household member's age is 18-64 and not a deleted person go to HHC.230; Else goto HHCCCI6.

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

(1) Yes
(2) No
(7) Refused
(9) DK

(Goto HHCCCI6)

Check item HHCCCI6: If all the household members are flagged with "A" or "D", set OUTCOME=223 and ACTION=31 goto HHC.240; If SCR_STAT = 2 (interviewed household), or SCR_STAT = 1 (screened household) and where anyone is Black or Hispanic, goto HHC.250. If SCR_STAT = 1 and no one in the household is Black or Hispanic; goto HHC.240

Not every household in our survey is asked all questions. I have all the information about I your household that need at this time. Thank you for your assistance.

FR:{You/Name} {HAVE/HAS} BEEN SELECTED AS THE HOUSEHOLD REFERENCE PERSON. IS THIS HOUSEHOLD MEMBER AN APPROPRIATE CHOICE? PREFERABLY A CIVILIAN ADULT?

(1) Yes, accept this person (HHCCCI3)
(2) No, select another person (HHREF_B)

HHREF_B Person number of the Household Reference: _________

[If HHREF_A = 1, store Reference Person's person number in HHREF_B]

Check item: If the person listed in HHREF_B is 14-17 years old, goto HHC.255; Else store the Reference Person's person number in HHREF_B; goto check item RPREL_CK.

You have selected a person less than 18 years old. Is it correct?

(1) Yes, continue the interview (RPREL_CK)
(2) No, select another (HHREF_A)

Check item RPREL_CK: Obtain the relationship of each non-deleted HH member to the HH reference person (get information on RPREL, DEGREE1, DEGREE2, DEGREE3). After exhausting all the HH members goto HHCCCI8.

FR: SHOW FLASHCARD H3.
What is {your/PX-name's} relationship to {you/RP-name}?

2. Spouse (husband/wife)
3. Unmarried Partner
4. Child (biological/adoptive/in-law/step/foster)
5. Child of Partner
6. Grandchild
7. Parent (biological/adoptive/in-law/step/foster)
8. Brother/sister (biological/adoptive/in-law/step/foster)
9. Grandparent (Grandmother/Grandfather) /
10. Aunt/Uncle
11. Niece/Nephew
14. Roomer/Boarder
15. Other nonrelative
16. Legal guardian
17. Ward

(2) Spouse (husband/wife)
(3) Unmarried partner
(4) Child (biological/ adoptive/in-law/ step/ foster) (HHC.270)
(5) Child of partner
(6) Grandchild
(7) Parent (biological/ adoptive/in-law/ step/ foster) (HHC.280)
(8) Brother/sister (biological/adoptive/ in-law/ step/ foster) (HHC.290)
(9) Grandparent (grandmother/father)
(10) Aunt/uncle
(11) Niece/nephew
(12) Other relative
(13) Housemate/Roommate
(14) Roomer/Boarder
(15) Other nonrelative
(16) Legal guardian
(17) Ward
(97) Refused
(99) Don't know

[If two persons in a household with RPREL = 2 or 3, goto HHC.264; Else goto HHC.260 for obtaining the relationship of next person in the household. If no more persons in the household, goto HHCCC18]

FR: READ IF NECESSARY:

Earlier I recorded {1st spouse/partner name} was {RP name}'s spouse or partner.
You have just reported {2nd spouse/partner name} is also {RP name}'s spouse or partner.
Which is correct?

(1) {1st spouse/partner} is the correct spouse/partner. Change relationship entry of {2nd spouse/partner}. (HHC.260)
(2) {2nd spouse/partner} is the correct spouse/partner. Change relationship entry of {1st spouse/partner}. (HHC.268)

FR: USING THE F1 KEY, BACKUP TO {fill name of 1st spouse/partner} AND CHANGE RELATIONSHIP TO FAMILY REFERENCE PERSON. WHEN FINISHED, PRESS F3 TO JUMP FORWARD.

{Are/Is} {you/PX-name} {your/RP-name}'s biological (natural), adoptive, step, foster {son/daughter}or {son/daughter}-in-law?

(1) Biological (natural) {son/daughter}
(2) Adoptive {son/daughter}
(3) Step {son/daughter}
(4) Foster {son/daughter}
(5) {son/daughter}-in-law
(7) Refused
(9) Don't know

Check item:If HHC.270 = 1 and (AGE (Reference Person)-AGE(PX) lt (12)) goto BIOCK1; If there are no more persons goto HHCCC18; Else goto HHC.260 for the next person in the HH.

You said that {you are/{name's} is} {subject name}'s biological {mother/father}.
There are only {1-11} years age difference between {you/them}. Is this relationship correct?

(1) Yes, continue the interview (HHC.260)
(2) No, change relationship (HHC.270)

{Are/Is} {you/PX-name} {your/RP-name}'s biological (natural), adoptive, step,
or foster {mother/father} or {mother/father}-in-law?

(1) Biological (natural) {mother/father}
(2) Adoptive {mother/father}
(3) Step {mother/father}
(4) Foster {mother/father}
(5) {mother/father}-in-law
(7) Refused
(9) Don't know

Check item:If HHC.280 = 1 and (AGE(Reference Person)-AGE(PX) lt (12)) goto BIOCK1; If there are no more persons goto HHCCC18; Else goto HHC.260 for the next person in the HH.

You said that {subject's name} is {your/ PX's name}'s biological {mother/father}.
There are only {1-11} years age difference between {youhem}. Is this relationship correct?

(1) Yes, continue the interview (HHC.260)
(2) No, change relationship (HHC.280)

{Are/Is} {you/PX-name} {your/RP-name}'s full, half, adoptive, step, or foster
{brother/sister} or {brother/sister}-in-law?

(1) Full {brother/sister}
(2) Half {brother/sister}
(3) Adopted {brother/sister}
(4) Step {brother/sister}
(5) Foster {brother/sister}
(6) {brother/sister}-in-law
(7) Refused
(9) Don't know

Check item:If no more persons, goto HHCCCI8; Else goto HHC.260 for the next person in the HH.

Check item HHCCCI8: If more than 1 unrelated person in a HH, goto HHC.300; Else goto END_HHC.

FR: PROBE AS NECESSARY TO ESTABLISH RELATIONSHIPS OF PERSON(S) NOT RELATED TO THE REFERENCE PERSON.

FR: DO NEW FAMILY NUMBERS NEED TO BE ASSIGNED TO ANY HOUSEHOLD MEMBERS?

(1) Yes, additional numbers (HHC.310)
(2) No, all are in family "2" (END_HHC)

FR: CHANGE THE FAMILY NUMBER AS NECESSARY.

Line #
Name
Family #

FAMNUM2[fill PX][fill NAME]

[Store new family # in FMX (family number)]

Check item END_HHC:Count the Number of Families in the Household.
Count the number of persons in each family.

(Goto next section -- Family Relationship and Verfication of Demographic Information).

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?

NCNAME 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?

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?

CP1TELNO (____)_____-________

(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: ________________
CP2NAME3Last 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?

CP2TELNO (_____)_____-______

(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.