FR: VERIFY OR ASK IF NAME IS MISSING OR WAS REFUSED OR NOT KNOWN.
ENTER 7 or 9 FOR ANY PARTS OF NAME REFUSED OR NOT KNOWN.
IF THERE IS NO MIDDLE INITIAL, LEAVE BLANK.

NAMVER_F First name of {subject name} is:_________________________
NAMVER_M Middle initial of {subject name}:________________________
NAMVER_L Last name of {subject name}:___________________________

(7) Refused
(9) Don=t know

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

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

Does {subject 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?

Name: ________________________________________
(7) Refused
(9) Don=t Know

Check item RCICCI1: If male, then go to RCI.060.
If female and (never married or age is under 14), then go to RCI.060.

What is {subject name}'s maiden name?

Name: ________________________________________
(S) Same as current last name (displayed above)
(7) Refused
(9) Don=t Know

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

Name: ________________________________________
(S) Same as current last name (displayed above)
(7) Refused
(9) Don=t Know

FR: READ TO RESPONDENT(S):
We also need {subject name}'s Social Security Number. The National Center for Health Statistics will use {subject 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 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 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 name}'s Social Security Number?

FR: ENTER (N) IF NO SOCIAL SECURITY NUMBER.

Social Security Number : _____ - ____ -______(RCI.080)
(999999997) Refused
(999999999) Don=t Know

FR: DO NOT READ TO RESPONDENTS(S):

YOU MIGHT WANT TO ENTER H TO READ SSN HELP SCREEN.

HAVE YOU CONVINCED THE RESPONDENT TO GIVE YOU THE SOCIAL SECURITY NUMBER?

(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.

FR: READ TO RESPONDENT:

The United States Public Health Service may wish to contact {you/your family} again to obtain additional health related information.

@ENTER (P) TO PROCEED

Check item RCICCI3 :If TELENUM = N go to RCI.096; If TELENUM = 7 or 9 go to RCI.092. (Note: Telephone number TELENUM was 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)(7) Refused (RCI.096)
(2) No (RCI.092)
(7) Refused (RCI.096)
(9) Don=t Know (RCI.096)

What is {your/your family=s} telephone number?

(1000000000-9999999999)
(7) Refused (RCI.096)
(9) 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 {Reference Person}?

FR: SPECIFY NAME AND RELATIONSHIP AND/OR OTHER VERBATIM RESPONSE. RECORD UP TO FOUR LINES OF INFORMATION. ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.

TELST_A ____________________________________
TELST_B ____________________________________
TELST_C ____________________________________
TELST_D ____________________________________

(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?

FR: PROBE FOR MONTH AND YEAR.

MVTIME_M MONTH: _______________
MVTIME_Y YEAR: ________________

(7) Refused
(9) Don=t Know

Where do you expect to move?

FR: PROBE FOR AS MUCH DETAIL AS RESPONDENT CAN PROVIDEC LOCATION, SPECIFIC ADDRESS IF POSSIBLE (STREET ADDRESS, APT #, CITY, STATE, ZIP]. RECORD UP TO FOUR LINES OF ADDRESS INFORMATION. ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.

MVINFO_A ___________________________________________________
MVINFO_B ___________________________________________________
MVINFO_C ___________________________________________________
MVINFO_D ___________________________________________________

(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/your family} 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:

CP1NAME_F First Name:___________________________________
CP1NAME_M Middle Initial:___________________________________
CP1NAME_L Last Name:___________________________________

(7) Refused
(9) Don=t Know

Check item: If CPINAME_L = 7 or 9 go to RCI.172.

What is this person's address?

FR: READ IF NECCESSARY:

If there is more than one address, please give us the address used most often.

CP1ADDR1 Number and street: __________________________________
CP1ADDR2 ____________________________________________________
CP1ADDR3 City: ______________________________________________
CP1ADDR4 State: ____
CP1ADDR5 Zip: ________ -
CP1ADDR6 Zip: ______

(7) Refused
(9) Don=t Know

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

FR: ENTER THE AREA CODE AND THE NUMBER OR ENTER (N) IF NO PHONE.

CP1TELN1 ( _____ ) _____ - ______
CP1TELN2 ______

(9999999996) Does not have a telephone
(9999999997) Refused
(9999999999) Don=t Know

What is the relationship of this contact person to [Reference Person]?

(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

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:

CP2NAME_F First Name:_______________________________________
CP2NAME_M Middle Initial:_____________________________________
CP2NAME_L Last Name:_______________________________________

(7) Refused
(9) Don=t Know

Check item: If CP2NAME_L = 7 or 9 go to RCI.172.

What is this person's address?

FR: READ IF NECESSARY:

If there is more than one address, please give us the address used most often.

CP2ADDR1 Number and street: ____________________________________
CP2ADDR2 ____________________________________________________
CP2ADDR3 City: _______________________________________________
CP2ADDR4 State: _____
CP2ADDR5 Zip: _________ -
CP2ADDR6 Zip: _______

(7) Refused
(9) Don=t Know

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

FR: ENTER THE AREA CODE AND THE NUMBER OR ENTER (N) IF NO PHONE.

CP2TELN1 ( _____ ) _____ - ______
CP2TELN2 _______

(9999999996) Does not have a telephone
(9999999997) Refused
(9999999999) Don=t Know

What is the relationship of this contact person to [Reference Person]?

(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/your family} again, when are the best times to call or visit?

FR: PROBE FOR DETAIL (FOR EXAMPLE EVENINGS, WEEKENDS, WORK TELEPHONE NUMBER, ETC.) RECORD UP TO FOUR LINES OF INFORMATION. ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.

_____________
_____________
_____________
_____________
(7) Refused
(9) Don=t Know

Check item END_CP:Roster end PERSONS

Go to next section -- Child section, or Adult section, or next family.