[p.57]
Appendix III. Questionnaire and Flash Cards
U.S. Department of Commerce
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
Bureau of the Census
Acting as Collecting Agent for the U.S. Public Health Service
U.S. Health Interview Survey
1. PSU ____
2a. Segment number ____
2b. Segment type ____
NTA ____
TA ____
B ____
P ____
LSDP ____
TA ____
B ____
P ____
LSDP ____
3. Serial number ____
4. Sample
B__
5. R.O. number ____
6. I.D. code ____
7. Book ____ of ____ Books
8. Street address (House No., Street, Apt. No. or other identification) ________
City ____
State ____
ZIP code ____
State ____
ZIP code ____
Segment List
Sheet No. ____
Line No. ____
Line No. ____
9. Year built - If "Ask" box is "X"d, complete this item before the interview
[] Ask __
[] Do not ask
[] Do not ask
When was this structure originally built?
[] Before 4-1-60 Continue interview
[] After 4-1-60 Go to Q. 13c, complete if required and end interview
[] After 4-1-60 Go to Q. 13c, complete if required and end interview
10. What is your mailing address and ZIP code? ____
[] Same as 8
City ____
State ____
ZIP code ____
City ____
State ____
ZIP code ____
11. Special dwelling place name ____
Type ____
Description of sample unit (Room No., Bed No., etc.) ________
Sample unit number ____
Type code ____
12. Type of living quarters
Description of sample unit (Room No., Bed No., etc.) ________
Sample unit number ____
Type code ____
1 [] Housing unit
2 [] Other Unit
2 [] Other Unit
13. Ask:
[] a. Are there any occupied or vacant living quarters besides your own in this building?
[] Y (fill Table X)
[] N
[] N
[] b. Are there any occupied or vacant living quarters besides your own on this floor?
[] Y (fill Table X)
[] N
[] N
[] c. Is there any other building on this property for people to live in -- either occupied or vacant?
[] Y (fill Table X)
[] N
[] N
[] d. None (item L)
ITEM L
2 [] Rural (14)
1 [] All other (Q1)
1 [] All other (Q1)
14. Do you own or rent this place?
[] Own
[] Rent
[] Rent free
[] Rent
[] Rent free
15 a. How many acres of land are included?
1 [] 10 or more acres (b)
2 [] Less than 10 acres (c)
2 [] Less than 10 acres (c)
b. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $50 or more?
[] 2 Y (Q1)
[] 4 N (Q1)
[] 4 N (Q1)
c. During the past 12 months did sales of crops, livestock, and other farm products from the place amount to $250 or more?
[] 3 Y
[] 5 N
[] 5 N
16. What is the telephone number here? _ _ _ _ _ _ _ _ _ _
2 [] None
17. Was this interview observed?
[] 1 Y
[] 2 N
[] 2 N
18. Interviewer's name ____
Code ____
ITEM N
Number of Hearing Supplements required _____
[p. 58]
Type A
1 [] Refusal (Describe in a footnote)
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
2 [] No one at home -- repeated calls
3 [] Temporarily absent
4 [] Other (Specify) ____
Type B
1 [] Vacant -- nonseasonal
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____
2 [] Vacant -- seasonal
3 [] Usual residence elsewhere
4 [] Armed Forces
5 [] Other (Specify) ____
Type C
1 [] Demolished
2 [] In sample by mistake
3 [] Eliminated in sub-sample
4 [] Built after April 1, 1960
5 [] Other (Specify) ____
2 [] In sample by mistake
3 [] Eliminated in sub-sample
4 [] Built after April 1, 1960
5 [] Other (Specify) ____
20. Record of calls at household
[1-7/Com.]
Date ____
Beginning time ____
Ending time
Beginning time ____
Ending time