APPENDlX 111. QUESTiONNAIREs

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I

21. Record of calls at household

Thn iturns holow show the exact content and nording of the basic questionnaire used in the nationwide household survey of the U.S. Nntionnl Ilcalth Survey. Tho nctunl questionnaire is designed for a household as a unit and includes additional spaces for reports on more than one person, clmdition, acoidont, or hospitalization. Such spaces are omitted in this illustration.

NOTICE - All information which would permit identification of the individual will be held in strict confidence, will be used only by person3 engaged in nnd for the purposes of the survey, end will not be disclosed or released to others for any purposes.

CORM NHS-HIS.1 (lW8) U.S. DEPIRTMEHT OF COMMERCE

R.rl..d ,,.ac..ea, BUREAU OF THE CENSUS

ACTIN *I COLLECTING AGENT FOR THE U.S. P”BLlC HEALTH SERVICE

U.S. HEALTH INTERVIEW SURVEY Book-- of- Books

2. Street address (House No., Street, Apt. No. or other identification) ISegnmnt 3. Year built - If “Ask” box is “X”d, complete

I this item b+forc tbe interview

_________- !Sheet

nAsk-z---F!YN_otask---

iNO.-

----_

---,---r--- When was this structure originolly built?

City , Slate 1ZIP code ’Lioo . 0 Before 4-l-50 0 After 4-160 Go to Q.13~. complet,

I I ; No.- Continue interview if required and end interview

4. Special dwelling place nome ,TYP~I Type code lescriptlon of Sample Unit

I Room No., Bed No., etc.)

1. Mailing address flf different from 21 0 Same as 2 5. PSU J egment 7. ,“;S;L, 8. Sample 9. R.O.

~~-~~_-__-_-__----_---City f State 1ZIP code

2. Type of living quarters (Mark appropriate box with an “X’y __t 1 1 n Housing unit z n Other unit- I

3. Ask: ; Oa. 0 b. 0 =. 0 None lltem Ll

,---1 a. Are there any occupied or vacant living quarters besides your own in this building?

_____________ - ____________ ---n-YesLFzfl-T~bl:!L.~-N~

1 b. A there any occupied or vacant living quarters besides your own on this floor’

-‘I _______________________________ --~_--_---~_Ye_S’Fizl_T~b4ex’__e_N_o~~

I e. Is there any other building on this property for people to live in - either occupied or vacant? 0 Yes (Fill Table Xl ON0

FfasHL 1 0 Rural (14 and 15) I 1 0 All other (161

14. Do you own or rant this placc? 0 Own (ISa) 0 Rent (1.561 f-y Rent free 11.w ________________________________________---~

5.. (Own or rent free) Dams this place have 10 or more acres?

0 Yes (I&l f-J No (15dJ b. (Renr) Dow the pIas* you rent have 10 or more acre.?

E, During the past 12 months did salts of crops, livestock, and 2 0 Yes 4aNo other farm products from the ploco amount to $50 or more?

d. During the part 12 months did sales of crops, livestock, and 3 n Yes 5DNo other farm products from the place amount to $250 or more?

16. What Is the t&phone number how? Telephone number 2f-J None

17. MOTOR VEHICLE ACCIDENT CHECK ITEhl 18. Was this interview observed? tOYes ZI-JNO

Review question 30 to determine how many motor vehicle sup lements need to be completed. (Fill a separate supplement for each if lfferent

accident reported) Name of observer

19. Interviewer’s name

Number of M.V. Accident n None (Enter ending time

Supplements Required in item 21.1

20. Noninterview rewon

4

TYPE A TYPE B

1 nRsIusn1 (Dsac;ibs in a foolnole) I n vacant-non-seaaana~ 2n Vacant-seasonal 1 n Demolished 2 n In sample by mistake

2 n No ona 81 home - repeated calls 3 n Usual residence elseivhere 30 Eliminated in sub-sample

I n Temporarily absent 40 Armed FOrCeS 4n Built after April 1, 1960

q

^OtherGS~xcJfy~~ E.n Other @pecJfy> sn Other Opacify~

3 7

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21. Record of calls at household WASH.USE ONLY

-- -- --

--- --- ---

-- --

la. What is the name of the head of this household? - Enter name in first column. yes* N,, la. Firatnama b. What are the names of all other persons who live here? - List all persons who live here.

C. I have listed (Read names.) Is there anyone else staying here now, such as friends, relatives, or roomers? 0 0 _2N d. Have I missed anyone who USUALLY Ii ves here but is now away from home?. . . . . 0 0

0 ---_____ 3 O?

e. Do any of the people in this household hove a h o m e anywhere else? . . . . : . . . 0 ’ Las1 n a m e

* Apply household membership rules.

2. How is related to (Head of household)? 2. Relationship

3. How old was on his last birthday? - Enter Age and circle Race and Sex 3. HEAD

1. Record the number of Hospitalizations, Doctor Visits, and days lost from work when reported. H I DV W L

-INi’) -(NPI -(Ss

06” UNopnc O N o m

) (NJ f.51)

C

II. Record each condition in the person’s column, with the question number(s) Where it was reported. Q. No Condition I 1

I I 1 II I I I

If 17 years old or over, ask: o 0 Under17 a~Ncver manic

4. Is --now married, widowed, divorced, separated, or never married? - P&arkone box for each person 4. I OMarricd 4mDivorccd 20 Widowed s0Sepsrawd If related ersons 19 years old or over are listed in addition to the respondent, say:

W e would r Ike to have all adults who are at h o m e take part in the interview. o 0 Under 19 Is your --, your --, etc., at home now?

I 0 At h o m e

H

If other eligible respondents are at home, ask: 2 0 Not at h o m e

Would you please ask --, --, etc., to join us?

(This survey is being conducted to collect information on the Nation’s health. I will ask about visits to WASHINGTONUSE doctors and dentists, illness in the family, and other health related items.) (HAND CALENDAR) ED TLD RAD The first few questions refer to the past two weeks, that is, the 2 weeks outlined in red on that calendar,

beginning Monday, , and ending this past Sunday, I-J Yes (5b)

50. During those two weeks, did stay in bed because of any illness or iniury?

b. During that two-week period, how many days did stay in bed all or most of the day?

____-________ - __________ ____ ---_--__-_ _____________

C. During those two weeks, how many days did illness

or injury ---__________________________~~~~~~~~---~~~--~-~~~~-~ keep from work? (For females): not counting work around the house.

-SL days tie) d. During those two weeks, how many days did illness or injury keep from school? ^d. UNO”C(Sf)

---_____________---e. On how many of these days lost from stay in bed all or most of the day?

Were there any (other) days during the past 2 weeks that had to cut down on the things he usually does because of his health?

in bed _-days _(aa)

g. (Again, not counting the day(s) lost from work )

lost ftum school ” f-J None (6)

How many days did he have to cut down for as much as a day?

If l+ days in Q. 5, ask 6; otherwise go to next person.

6a. What condition caused --to during the past 2 weeks? &a.

---_-_______---0 Yes (6.2) b. Did any other condition cause him to ^during that period?

b* ONO~PJ

---___---

______---_______-___---.---Enter emdi~irmr In item C

C. What condition? 5. &ask 66

4 8

---

~~~~---_____________________---~-~ the past 2 weeks? 14..

.-_ IJ No condition (Z&j

---

--- --

-- --

I

^260. ^Has been in a hospital at any time since

I

^Xa.

I

^C]Ycs (266) ONo

lItem C) I ,

I

b. How many times was in a hospital since a year ago? 1

I b.1

I -Times fItem C) 1

270. Has anyone in the family been in a nursing home, convolesccnt home or [I Yes 1276)

slmilor place since 0 year ago? ~No as)

b. Who was this? - Mark “Yes” in oerson’s column. 27b. r--iYcc

l~~,~-eac6,~~~s~,-~ar~ch ask: - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

---__---C. During that period, how mony’times was in o nursing home or similar place? C. -Times Otem 0

Fnr each child 1 year old or under, ask: MO~lh ; D.-Y ;YCar

28.. ^{When woe} ^born? If on or after the date stamped in 26, ask 28h. 28.. I I

~~_---~--~---~---.~--~---b. Was born in a hospital? b.

If “Yes” end no hospitalizations entered in his and/or mother’s column, enter “1” in 26 end item C. 0 Yes UN0 II “Yes” end a hospitalization is entered for the mother and/or baby, ask 28~.

---_---

--.---c. Is this hospitalization included in the number you gave me for -4

If “No:’ correct entries in Q. 26 and item C for mother end/or baby. ” nYcs nNo

29. YII~ npplicnblc - Use for footnotes

These next questions ore about motor vehicle accidents, that is, accidents involving cars, trucks, bores, motor-cych, and so forth. WC arc interested in all types of motor vehicle accidents even if no one was iniured.

300. During the post 12 months, has been in o motor vehicle accident either as o (driver), posscngcr or pedestrian? 30.. UYcs 1306) ONo CNPJ _________--_---__---~---~~~~~~~~~~~~~~-~-~~---~.-~~~~~----~----~

b. How mony motor vehicle accidents has been in during the post 12 months? b. Number of accidents

-__---_---~~~---y , tear

E. On what date(s) did the accidcntM happen? =. . hlanth

-T-D,-‘-:--I ---~--~---~---l---

d. Was -L lo ony other motor vehicle accident during the post 12 months?

1“~ ull pereons 14 ycors of sge and older, arlk:

OYCS OIti

31.. Has driven o motor vehicle during the post 12 months? 3’a* xll-JNo NVP.,

__________-_---~~~~~---~.---.

00 i-J Less than 1 year

b. How many years has been driving? b.. -Number of years

R

I*‘nr pareone 19 yonre old or over, chow who responded for (or wes present during the asking of) Q. 531. 1 0 Responded for self-entirely If pereons responded for self, show whether entirely or pertly. For pereoee under 19 show who responded 2 0 Responded for self-partly 9.5.31 for them. If eligible respondent is “at home” but did not respond for self, enter the reason in e footnote. Pcreanwss rcsp 1

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-- --

--- ---

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CONDITION 1 I 1. P*rson number

Enter person number and “name of I

condition” and ask question 2. I Nome of condition

Ask for all conditions. I

2. Did ever at any time talk to a doctor about his . . .?

---_---Do not ask for Cancer. b. What war the caose of. . .?

For ALLERGY O R STROKE, ask:

e. Who+ par+ of the body is affected?

Show the following detail:

Ear or eye. . . one or borh Head . . . skull, scalp, face Bock . . . .upper, middle, lower

Arm. . . . .shoolder, upper, elbow, lower, wrist, hand; one or both

FILL QUESTIONS 44 FOR ALL ACCIDENTS O R INJURIES

4.. Did the accident happen during the (4b) 6.. Was a car +ruck, bus, or other m&or vehicle

past 2 yews or before that time? involved\n +he accident in any way? ,a Yes (6bl 20 No (71

---_---~---~

b. When did the occident happen? f--J Last week b. Was more tfioo one vehicle involved? 0 Yes ON0

Enter month and year: lark one box.

---_---c. War it (ei+her one) moving o+ the time? 10 Yes 20NO

r [ !gg:i months

7. Where did the occident happen?

10 At home (inside house)

Ask for all accidents or injuries: ~0 At home (adjacent premises)

5a. At the time of the occident what part if the body woe hurt? an Street and highway (includes roadway)

What kind of injury was it? Anything else? 40 Farm

. 50 Industrial place (includes premises)

Part(s) of body Kind of injury 60 School (includes premises)

. _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 70 Place of recreation and sports, except at school _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 80 Other (Specify the place where accident happened)

If accident happened BEFORE 3 months, ask:

b. What port of the body is affected now?

How is his affected? Is he affected in any other way? 8. Was at work ot his job or business when +he occident happened?

Part(s) of body Present effects 10YM

20 No

---_---‘---e-w- s~~ilein*rmdservices

_---_---_-- 40Under17attimeofaccident

--- --

-- --

well enough to read ordinary n.wspap.r

b. Did ho hw. to cut down for as much as a day? I-J Yes 0 No (fda)

11. How May days did h. hav. to cut down during that 2-weak p.riod? -Days

12. During that %w..k pwiod, how many day. did his . . . keep him in bed all or most of the day? - Days 000 None 13. Ask if6 - 16 years: How m.ny days did his . , . keep him from school during that 2-week p.riod? _ Ihys(f5u) ~$-JNorte(f~a) 14. Ask if 17t years: How many days did his. . . keep him from

work during that 2-we.k period? (For females): not counting work around th. house? _ Days 000 None 0 During 3 m0.5. (fdb) 15.. Wh.n did h. first notic. ____________________---his . . . ? - Was it during the past 3 months or before that time? 0 More than 3 mos. ago (16,

I-J Past 2 weeks (IS@

b. Did h. first notice it during th. past two weeks or before that time? 4 i-J More than 2 wk.. ago (AA)

________________-_______________________---I 0 Last week

c, Which w..k, last week or the wok before? 2n Wk before C.4.Q

5 0 3-12 months

16. Did first notic. it during th. past 12 months or before that time? 6 0 More than 12 ma.% ago

reported i” pmbe Q. 16

AA 1

^Continue ^if renp;wt;l ; pmbe Q. 25 Otherwise, go to next condition

0 “Yes” in question 2 (18) n “No” in question 2 (17)

17. During th. past 12 months what did do or take for his . . . ? Anything else? Write in - _{124 )}

0 0 Discovered by doctor (20,

Z-Days a-Months

18. Aftw __ first notic.d som.thing was wrong, how long was it befor. he talked to a doctor about it? (Estimate is acceptable: B_Weeks

5 -Years 19. 6.f.r. talkal to a doctor about his . . ., what did h. do or take for this condition? Anything els.? Write in

-20.. Do.8 N O W tak. any m.dicine or treatment for his . . .? 1 OYes zf--JNo(2f)

b. Was eny of this mwdisine or tr.atm.nt r.comm.nded by a doctor? 1 OYC-3 20NO

21. Has h. EVER hod surg.ry for this condition? 1 OYes 2nNo

22. Has h. EVER b.m hospita1iz.d for this condition? 1 OYer ZI-JNO

23, During tb. pa.1 12 months, about how mclny times has s.m .I ta1k.d to a doctor about his . . . ? -Times ooo n None 24. About how m.ny days during th. past 12 months, has this condition kept him in bad all or most of the day? -Days W O O None 25a. How oft.n do.. his . . . bothw him - all of th. time, a.m. of th. tim., .t newr? (Mark m e box) If bothred .at all, ask 256.

1 0 All the time (25b) 2 0 Some time (25b) 0 0 Never 125.3 3 0 Other If not bothered, go to 25c.

~~~~~~~-~--- @Ecw.---~- _______

b. Wh.n it do.. both.r him, is h. bothemd a groat d.al, som., or wry little? (Mark one bar) I 0 Crent deal (AC)

_-_________ ‘_cI~“_“_I”_“_--~--Jo~lifll~~~~~_4~o~hhc_rIsp_acily)---~ ^cw

I 0 Yes (Next .xmditio”, C. Do.9 .till hav. his , . . ?

----_--_-_____-_----__L_________________--- 0 No (25d)

d. I. this rendition compl.t.ly cur.d or is it under control? 2 0 Cured ~%,a 0 Und. cont.

(Next cona) 4 0 Other

---_-_________--- C - (Specify) (Next Cmd.)

0 0 Less than one month

. . About how long did hov. this condition b.for. it was cured? -Months -Yeara

53.

I iw e or. also collecting information on hospital and surgical costs. Before1

HOSPITAL PAGE l I ask the next questions, it would be helpful if you would get the hospital1 1.C. or Dum.

l bills and any surgeon’s bills for the hos itol stoy(s) you told me about l

for --, --, etc. (and tb. doctor’s bill P01 --delivery.) 1 1. Person

number-USEYOURCALENDAR Make sure the YEAR is correct Y O U said that was in the hospital (nursing home) during the post yeor

-3. What is the nom. and address of this hospital (nursing home)?

___________________rNai%;

-I I

Street ’ City (or county) ’ state

I I

4. Howmony nights was in the hospitol (nursing home)? *

5-a. How many of these nights we,. during the past 12 months?

____________________---enter an adequate desCiption.

Show CAUSE, KIND, and PART OF B O D Y in BB~C

ormol at birth?

Ea. Were any operations

---_--_____-____i________ performed on during this stay at If name of operation is not

known, describe what was I

b. What was the nom. of the operation? --+

done.

I C. Any other operations?

b. What kind of place did go to? (Specify)

Interviewer: If the place in 9b is a hospital, nursing home or similar place, was a Hospital page filled for that stay?

Hospital page filled (12) 0 Hospital page not filled (Fill Hospftal page far mreportad stay after completing Q ’e 12 - 18 for this aby)

IO. After leaving the hospital (nursing home) how many days did

wo I-J None XXI 0 Still in hed ia days

have to remain in bed all or most of the day?

Il. ALTOGETHER how mooy days was confined to the house

am 0 None XXI 0 Still confined 10 house 0 days

after returning home from the hospital (nursing home)?

54 0

---

--- --- --

--- --- ---

Enter the person number and the dote of entry

12. h I k qucntions 13 through 18 for each complered hospitalization

box 13. Whot war the totol amount of the horpitol bill for this stay?

I-

^DOnot include any doctor’s or surgeon’s bills. -0 Estimate, bill received 0 ^Estimate. bill not received 0 From bill1

I 140. Did (will) health inruronce

---~---LJP~~*L~~poy any port of the hospital bill? 0 Yes Name of insorance plan Dollars Cents

-.--b. What is thr nomc of the insurance plan?

----______---

__

C. Did (will) pay port of this hospital ->-m---;---c---any other hmlth bill? insurance plan 0 r-IN0 Yes (Reesk 14.5)

.____--- .--_---

Ask for each health insurance plan named, then o to 15b.

l i

d. What was (will be) the amount paid by (name of p7 an)?

Enter tutu1 amount paid by health insurance in line A. Soorce of payment

Enter nn amount paid by Social Security Medicare in line B. AL. I 0 Health insorance

h p’tol bill’ (All plans excluding Medicere)

15o. Whz pl- a (wilga_r)-th -e_Ol---.--- _--____---~

b. Did (you or) any othrr person or agency pay 0 Yes (15~ and reask 154 )

ony other port of the hospital. bill? 0 No IlSdorhl. C&&ltm J B8. 2 0 Social Security Medicare

---_--_-___________--- ._-___---~-~

e. Who war this? c :. 3 0 Self and family in household

,_______---~-~

0 ‘. 4 n Other (Specir,q -/

d. Whot was the omoont poid by --?

I i

b. I. the $ for the surgeon’s (doctor’s) bill included in the f amount you gave for the hospital bill?

1 0 Y M (In n footnote indicak the actual amount of the hos ital bill after deducting the surgeon’s (doctor’s)

hills; also indicate any than es in the amounts poi a by health insurance or other sources if the entries 4l-J No (17) in questions 14 ond 15 inclu 6:e payments for expenses other than the hospital bill.) (17)

C. B 0 Self and family in household

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

c.!!k_w.rthkil- D.lo b ;her~p~=if~~t --- t

d. What was the amount paid by ?

1’9. NOTE: If the condition in Q. 6 or 8 is on Card D, or there ore “ 1 ” or more nights in Q. 5b. a Condition page is required.

I

^Ifthere ia no Condition page, fill one after completing all required Hospital pages.

55:

40 0 Hospital Out-Patient Clinic 100 Telephone

I OI OGeneralPractitioner

q

Speci&t

I What kind of specialist

32a. (Not counting Social Security Medicare)

Is anyone in the family covered by hospital insurance, that is, a health I-JYes 120

insuranc=g~n_w_hi~h~~ra_n~p~rtofahb~~~i~l_b~l~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ a?2 Pd,- _ .-

---_----_ ---_----_ A.-Who____________________--- insurance? (else) is covered by hospital

If all persons BT~ covered, go to 32d b.c 8 0 Covered

-_____-_---___________________________---.of the United States? _-.---Yes (38b) I] Nn (NP)

b. Was any of his service during o war? b. OYes(NP) UNn

---

c.Woshelookinaforworkoronlayo~~o~~~b_l~ ---___ ---__ ________________________

d. Which - looking for work or on layoff from a lob? (other) SOWC., such as, loss of poy insurance, workman’s sompensotion or State temporary disability insurance?

---3--- public essistonce, relief, or welfare

~~~-~___--___~----__---~~~---~---~--~---money from State or local governments? 0 No (Household pa&)

OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS Public Health Service Publication No. 1000

Series 1. Programs and collection procedures.- Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data.

Series 2. Data evaluation and methods research.- Studies of new statistical methodology including: experi

mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory.

Series 3. Analytical studies.- Reports presenting analytical or interpretive studies based on vital and health statistics, carryingtheanalysis further than the expository types of reports in the other series.

Series 4. Documents and committee reports.- Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates.

Series 10. Data from the Health Interview Survep.- Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey.

Series 11. Data from the Health Examination Survey.- Data from direct examination. testing, and measure

ment of national samples of the population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with reepect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons.

Series 12. Data from the Institutional Population Surveys.- Statistics relating to ‘the health characteristics of persons in institutions. and on medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients.

Series 12. Data from the Hospital Discharge Survey.- Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals.

Series 14. Data on health resources: manpower and facitities.- Statistics on the numbers, geographic distri

bution, and characteristics of health resources including physicians, dentists, nurses, other health manpower occupations, hospitals, nursing homes, and outpatient and other inpatient facilities.

Series 20. Data on mortatity.- Various statistics on mortality other than as included in annual or monthly reports -special analyses by cause of death, age, andother demographic variables, also geographic and time series analyses.

Series 21. Data on natality, marriage, anddivorce. - Various statistics onnatality, marriage, and divorce other than as included in annual or monthly reports -special analyses by demographic variables, also geographic and time series analyses, studies of fertility.

Series 22. Data from the National Natatity and Mortality Surveys. - Statistics on characteristics of births and deaths not available from the vital records, basedon sample surveys stemming from these records, including such topics as mortality by socioeconomic class, medical experience in the last year of life, characteristics of pregnancy. rtc.

For a list of titles of reports published in these series, write to: Office of Information

Kational Center for Health Statistics U.S. Public Health Service

Rockville, Md. 20852

In document Current Estimates (Page 54-65)

APPENDlX 111. QUESTiONNAIREs

I