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) Don't know (Check item RCICCI1)

What is this other first name?

NCNAME Name: _____________

(7) Refused
(9) Don't know

Check item RCICCI1 : If HHC.040 = 1, 7, or 9 go to RCI.060; Else if HHC.040 = 2 and HHC.460 = 5 or AGE less than 14 go to RCI.060; Else if HHC.040 = 2 and HHC.460 = 6 and HHC.490 not = 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) Don't know

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

(S) Same as CURRENT last name (displayed above)
(7) Refused
(9) Don't know

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) Don't know (RCI.075)

FR: DO NOT READ TO RESPONDENTS(S): YOU MIGHT WANT TO ENTER (H) TO READ SSN HELP SCREEN

Have you now convinced the respondent to give you the SSN?
(1) Yes (RCI.070)
(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) Don't know (RCI.096)

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

(1000000000- 9999999999)1000000000-9999999999 (RCI.093)
(999999997)Refused (RCI.096)
(999999999)Don't know (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) Don't know

{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) Don't know (RCI.100)

Approximately when do you think that will happen?

MONTH: ____________
YEAR: ______________
(7) Refused
(9) Don't know

Where do you expect to move?

Number, Street, Apartment Number: ____________________
City: ___________________
State: __________________
Zip: ___________________
(7) Refused
(9) Don't know

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
CP1ADDR3 City : ____________________
CP1ADDR4 State: ____________________
CP1ADDR5 Zip: _____________________
CP1ADDR6 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) Don't know

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) Don't know

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
CP2ADDR3 City : __________________
CP2ADDR4 State: __________________
CP2ADDR5 Zip: ___________________
CP2ADDR6 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) Don't know

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) Don't know

If we need to contact you again, when are the best times to call or visit?

CINFO1 __________________________
CINFO2 __________________________
CINFO3 __________________________
CINFO4 __________________________

Check item RCICCI4: Go to child questionnaire, adult questionnaire, or next family.