CONDITION LISTS 1 AND 2

Questionnaires and flashcards

H. CONDITION LISTS 1 AND 2

-x

N., you

1

-I to respondent(s) and ask list specified in A2:

lamg.lng bm.delis* .fm.fic.l condilio.s. T.llm. ifa.y... i.6. f.milyh.s .nyof6.s. .o.&*l.ns, .rn. if WV. mqn+i.n.d th.m kdoro.

1., D..s.ny.n. i. !h. famlly(read n.mes}tfOWhav. - 2.. 0... anyon. in fh. hmllY{m.d ..mes)NOWh.v.

-If ‘“Yes,” ask lb and c.

b. Wheisfhls?

c, Oo.%anyon. .ls. NOWhov.

-Enter .onditio” and letter inaPPmPriote person’s column.

A. PERMAtkENT stlffn.ss .ranyd.f.rmify .fth. fa.t, I.g, flng.rs, arm, or back? (Permanent stiffness -@ints will

“*t RI*V* at all.)

--- -.

B, Pamlysi. .fm.y kind?

Id. OURINGTffE PAST 12 MOffTHS, did..y... i. familyily h.v. -lf”-Yes.”’.sk Ieandf.

●. Whe w., ibis?

f. OURING THE PAST 12 MONTHS, didanye.. .lho ho..-Enter condition tmd letter In appropriate person’s column.

Conditions C-Nond Varecondilions af{ectinz the bone a“d m“SCh

Conditions O-tJ and W-Z ore conditlo”s offecti”c the skim

C. Arthriii. ofa.ykind.t Reosk Id

Rh..nmti,m? P. Ecz.m. m Pswlasls?

---

---(*1/% a.mo) or

O. Gout? (...rh...h.. is)

--- .

---

---Q, TROUBLE witk dry or

E, L.mbqw? Itching skin?

---

--- . --F. Oslwnyehlis?

(.s.f..+h-mv.h-ly.’tls) R. TROUBLE with .cn.?

--- -- ---

---L At,ickkn..?

II I

U. O.tm.liti* .r any .th.r skin tro.bl.?

--- --- -.

J. A#p.der,.pti, ed

--- -- V. TROUBLE with Eon..

cweh. s, flatf..t, o, K. Cu:watur. of th. spin.? clubfoot?

--- -.

---

--L. REPEAI’EOtroubl. with W. TROUBLE with i.grown n..k, back, .. spin.? te.nails or fl”g.r”oils?

--- -- ---

--M. Bu,siIis otSynovitis? X. TROUBLE with b+nlons,

(.in.o.vy.’tls) corns, er..llvs.s?

--- --- --- -.

N, Anydis..s. .f th. Y. Any dls~s. of A. h.ir

m.scl.i or t.ndo.s? or *C. I.?

O. Atumor, .yst, .rgrowth Z. Any di,.m.. of +h. lymph ef th. skin?

0s2,,4...,.!

—

2 .“)’es,”

ask 2b andC.

b. Whoi, this?

. . Oo.s any... .1s. NOW h.v.

-Enter co”dirion and letter inaDDmDriate Derson’s column.

{}

Heorin~

A-L ore conditions affecti”~ Vision Speech Cmditions O-Wore impairments.

Conditiom YandZ.ffe

A. O., fn.s. 1....0, both ..,s?

--- .

B. Any .th.r tm.bl. h.ari.f with . . . or both●m?

. - . . . ___________________ .

[. Tinnitus or ringing in th. oU,S?

--- .

0.Blimdn.ss i. . . . or bath .y.s?

--- .

E. G-,..1,?

---

-F, G1.a.cmm?

---G. Color Mind”.ss?

--- .

H, A domch.d t.tins or my .ih.r condition .f *h*

r.ti”o?

--- .

1. +&rtiH. sning with ~orbathqs EVEN wfmn wmrimg gf.ssm?

--- .

J. A .l.ft P.l.t. .rH.r.liP!

--- .

K. Smnvn.ring or StLIII.ring?

---

-L, Any oth.r sp..ch do f,et?

--- --- . U. A missing fing.,, hand,

., am; M*, foot, ., l.fl?

--- .

N.A missing (bm.at), kidn.y, ..1..s?

,ervous system.

Reask 20

0. Palsy m C.r.bml Palsy?

(s.r’..b1)l)

---P. Paralysis .f.ny kind?

---Q.C.rvafu,. of th.spin.?

---R. REPEATEo q,..bl. wid ka.k .,spi..?

---S. A.y TROUBLE with f.11.m .,ch., ., flotf..t?

---T. A .I.bfo.t?

U. PERMANENT stiffness or any Af.rmiiy of th.

foot, I.g, .cfmck?

(Permo”e”t *tiff”es* -i.i.ls will met m.v.

at .1[.)

---W. PERMANENT stiffn.s.

or anyd. fwmity of tb.

fi.g.rs, hand, . . arm?

---W. M..tal ,.ta,dalio.?

---(. Any condition caused by a.?.cid.m or~l.ry

p;;:.;$: ;“;

* ..ondition?

---f. Epil.psy?

--- .

L REPEATEO C.. VUI,{O.., x.izum., or bl..kc.ui.?

H. CfXfDITION LIST33 AND 4 Read torespondent(s) and ask list soecified in A2:

ye’

c,M“,s.,,

If ““Yes,”’ ask3band c.

b.Wh. WC, this?

c.DURING THE PAST T2 MONTHS, did anyone .1.. how -Enter condition ondletter inowmwlateperson.s column.

f/ake no entry in item C2forcold; flu: red, sore, or strep thrc.at: o.’%lrus.-even ifrep.xwdln this list,

Comfitlons offectinc fbedigestive system.

L Gdlsteno’?

---L Ann:l:: gallbl.dd.r

---:. Cirrhosis d III. Ii,.,?

--- .

1.Fa~lIv.c?

---!. Jf.pallis?

---‘.Y.llow @undlc.?

---i. Any dim, h., trwbh?

---1. Any dis.a.e ef ~.

FQ.crms?

---An A.,?

--- .

, A hernia w ,uphtm?

--- .

. Amy dlsea,. of AI.

.,.phaws?

--- .

. Gastritis?

--- .

. FREQUENT indigestion?

,,, ,44.,,,

l.mgaing mr~dalist .fmAicol ”conditi . . . . T.llm. if..yen. inth. bmily ha.

!S”S mention.d th.m Wan.

So. OURING THE PAST 12 MONTNS, did.ny.m. i. Pm family (read norms) h...

-1

P. Oiv.ftieuliti.? --(Oy..v.r.tlc-y.o.ly. Ii.]

---}

Q.Colitis?

---1

R. A spastic .s1..?

---1

S. FREQUENT.CWIIP. IIWI --

---IT. Amy dim, bowl ,twbl.1

-+---I ^V.Cone.,

^..l*n, ^.rr..lum?^{of ih.} ^stomach,

-p_-

---w. O“ri”g fh. -St 12 months, dider.y en. (.1..) -- 1. th. family have .ny

.dl. r.ondifie” .f th.

di~.stlv. S~SNM?

--If”’Yes,’’ask: who WE, tkis? - Whet Y/o, fh. condition? Emer _- inllern C2. THEN

rens k W.

had any of th.s. .o.difi..s, .v.. if

40. OURING THE PAST 12 MONTHS, did a.y... in the family {read .omes)hov.

-If-sk fb ondC.

b. Wh.W.S !his?

c.OURING THE PAST 12 MONTHS, did my... .1s. h,.. -E“terconditio” a”dletter inawrwriatepemo”-s column.

H

A. d.my.;:~or oth.rtbyroid

---

--B. Oiab,tss?

---

--C. Cysti. fikm. i.?

--- __

D. Anemia?

---

--E. Epil.psy?

--- __

F. M.1tipi.s.1.rosis?

---

--G. Miswoin.?

---

--L Sciatica? (si.oti.kuh)

--- II

--1. H.phritis?

__________________ __

K. Kid.. ysto..,?

--- __

L. An~;$orkidnoy

---

--4. Bladd.rtrwbl.?

---

---L P,esto?. tr..bl.?

---

_-). A.ydisoas. oftb.

“NW. .rewy?

--- __

‘. Any.th., f.mal. t,oubl.

---

--Glandular disorders

Blood disorde,

Condition affectin~ the nervous system

Genito.urmwy conditions

). Came., ofanyki.d?

H. CONOITION LISTS 5 AND 6 toresp.andent(s) .ndaskltst sPecifiedin A2.

lam~i..

. . .

*.t..li stsfmfdiealc~ dititnsns. T.llmeif anyon. inh. family he. hdrnv.f *h*s. .on&ti . . . ..v.nff sw m.ntl.ned Am ‘dove.

m. Yf.s a.yor.. in tfm Ymnlly {read names) EVER bad

-(f “yes.”” ask 5b and c.

b. Who Was this?

c, Has anyono AC EVER had

-Emer condition and letter in qprop+icwe p+rs.m-s c.alunm.

Conditions affecting the heon and ci,culom-y system.

k. Rheumatic fw*r?

G. A sirok. . . .

---

--C.r.brovasculor oceid.nt 1. Rfwumaflc hart dlsrnsw? (s.r’a-br. v.. ku.1.t) --- ---- --

---‘%rw$i!!%’i-l lH”tkwO’Of”

]~

.--- --

---1. An@no P+chmis?

1. Ceng.nltml h~rt disco,. (p.k’to-ris) .--- --

---~

d. DURING THE PAST 12 bfONTHS, did OnyC+l. in #+.

family hovo -1( ““Yes,”’ ask Se .nd f.

. . Who we, this?

f. DURING THE PAST 12 MONTHS, did Oily*. ●ls. fWO -Enter c~didon and letter in opp@riate person”s column.

Ccnditi.ms affectinz the heart ond circulatory system.

‘“Dam”gdh”r’v”’v”” J

.---1,h:eardia o,Rapid

--- 1.

‘“A’Y””’’’’’’MJ’’”’J

.---.

Amwwxysm?

(.. y.a.rixm)

--- .

.

Ally‘IA Gt.tS?

I

,.1) (.4.,,)

—

-- .-

--—

—

i -R:-!?!’:!??--- -.

S. V.vi.as. veins?

---

--T. Homonh.ids . . Pil*a?

---

--U. Phl.biti. or Thrombophl.bltis?

--- I

--—

6 —

b. DURING THE PAST 12 MONTHS, did any... i. th. family

@@=)hOv*

-If“Yes,”’ ask bb and c.

b. Who W.. this?

. . DURING THE PAST 12 MONTHS, didmy..- d.. ho.. -Enter condit ton and fetter in oppropnate person”s column.

Make no emty in item C2 for cold; flu; red. sore. or strep tbmot; or ..virus-- eve. if reported m th,s list.

Conditions affecting the

L Brmdftis?

---B. Branchi.cto% is?

(bmmg ka-~ t.h-si.)

---:.

---^Ash.?

D.Hay f...r?

---E.AIW.1 POlyP?

---F. Sin.. tr..bl.?

---& A doflocted or d.vi.fd

“.s01 a.ptum?

---1.●T.nsil fitis0. ..lOtg.-m.ns ef i’. tonsils or wkoids?

---1.“L.iyngitis?

---L Atumor, cyst, or growth of *h. b,on.hi.l tub.

or 1“”9?

!Spl—

---—

torysystem.

Reask 6a.

(. Emphys. ma?

---. ---. Pt---.ulisy?

---4. T.b.rc.l.. is?

--- .

{.

Amobs..s. of *h. lung?

--- .

1.A I.mci, cyst, . .growth of NW IbIO.t, larynx, or tt.eh..?

---3. Any w.rk.r.l.t.d t.splra tmy condition such as dust .nih.l~s, sill.esis or p...-m.-.o.sis?. sis?

-..-____-_---_-I. During *h. ~St 12 MUllhS did any... (.1s.) i.h.

family h.,. any .th.,

2:%7{W’:317’?:Y ask: Mm w., AIS?

Who* W., t’. cendillon?

Enter i“ ttem C2. THEN mosk O.

— -.

---.

--—

‘Ifreported i“ 16is list only. ask:

1. Hew nm.y tim.s did -- h.v. (_n) i. *h. p.st 12 months?

If 2 w more times, enter condition in item CZ.

if only I tfme, ask:

L How long did iti last? If I month or longer. enter i“ item C2.

If less than 1 month, do not record.

ff tonsilsor denoids were removed duri”z pust 12 momhs, emu the .cmdition causing renw.al in item C2.

,

“n. b,’r. , me=

I

^“,..., ^-., ^..,. ^”^,

,.

^““.. ^{, tab} ^r-w= ““..,,-...,”. .

Refer to C 1, ““HOSP.”’ box.

1. P*rs.n .Awr

!. Y.. Ad .erll.r ehot -- w.. . pd.nt in th. h.spifol sine. (13-month hosDit.1 date] o year Mamh claw v.,.

q.. On what dam did -- ..*, th. hospital ([th. last timiih. tlm. b.1.r. that])?

Record each entry dote in a separate Hospital SI.Y column. 2. 19_

1. How many .Iqhts was -- i. the h.spit.l? 3. - @ N~e @f*x! H-9)

—N@,s

1. For what . ..diti.n did -- ..t.r th. h..pit.l? 4. ,❑Nwm.1d.llvery

.For delivery ask: . For newb.mn osk: . F.x initial ‘“No condition’” ask: z❑NUMI =t bj,~

} (5) Was this . .cim.l d.liv.ry? Was ih. baby nomml at birth? Why did -- .oi. r th. h.spiml? s •l No . ..d Lt,..

If “’No, ” ask: If C-NO,,, osk: . For tests, ask: ❑ccdi:lcn

What w., th. matfer? Wh.t was th. m.w.r? Whet w.,. th. ,.,”It. of th. t..t.? )

If no results, ask:

Why were the t.sts prf.nned?

Jl ❑%I$:::e%:xh;i:l:r%%ltlm

JI

^Refer 10 questions 2, 3, .md 2-week reference periwi 1“ C2, THEN 5)

~ Il. nights I. Mva.k r.f.r.nce mrkd (5)

m. Did -- fmv. any bind of sutgsry or .p.ratl.. durin~ this stiy in *h. hospital,

including ban. ..tti.gs and stitch..? so. li-JYe* z❑NO (LI

--- ---- ---b. Wh.m w.. *h. am. of *h. surg.ry ., .pwstlon?

If name of operation not known, describe tial was done. b. (1)

(2)

(3) --- . ---- ---. ---. W---.---. th.r. any .tfmr .urg.ry or .p.mti.n during this SIQY?

. . ❑Y.s Nf.,sk 54●d C) ❑No

,. Wfm?i, *h. new,. .nd add,... ofthis hospiic.l? N.rm

Number .nd scram

CK2 w Ccunty stat.

00TNOTES

,.” “,s., ,,,,2, ,4.,.,,,

CDNDITIDN 1 IParson No._

1, Nmme●f c.mdl~lon

Mark ““2.wk. ref. pd.” kox without ask!nz if ““DV”’ or “’US’”

in C2 as source.

2. When did[--/any...]Imst s.... *elk t. a d..ter d, .atlslamt abut --

(c_n)?-o❑Irw,rvl.w w“k (RmSk 2) s❑2 yts.. 1..s dIWI 5 yrs.

I❑l.wk. ref. Pd. 6❑5 W*. or mot.

2❑Ov.r 2 wa,ks, 1.SS than 6 m... 7❑Dr. . . DK wh,n ---3 a 6 mOS., 1.ss than I Yr. 8❑OK if 0,. s...

40 I Y... I.** than 2yrs. } (3bJ

s I-T or. never seen

—

3a.(Earli.r YoU told MO about -- fsmdMD,D)) Did tko doctor or assistant ..[1 the (~) by . me.. t.chnlc.l . . specific memo?

,

❑Cd.n Blhdn.ss (NC) z❑c,”.., (2.1

}

.❑Old .s. (NC)

‘❑%%’ d%fl.~ (6J , n o,hw (3.) v.s..tomy

---c, What was tfm C. US. of -- (smndition in 3b)? (Specify) J

---

---Mark box If accident or injury. o❑ Accident/inMy (5) d. Did th. (condition in 3b) r.svh from . . a..ld..t or l.iufy?

!❑Y.S (6J 20N0

---,-, --- ~ ____________________ ,---Ask 3e if the condttmn name m 3b includes any of the following words:

Allmom can.., 01s,.,. Prebl.m

An.mla C..ditio” Dis.td.r R.pt”,.

Asthma cyst G,.WII T,eubl.

A*$ack D.f.a M.msl. s T.me,

Bad Uk.,

●. What kind of (condition in 3b) is it?

SPeCi(y

---Ask 3f only ,f ollerzy or stroke In 3b-t:

f. HOW d..s th. lill.rsy/strok.l NOW .H..t --? (SpecifY) J

For Stroke, fill remainder of tits condition pate for the first present effect. Enter in item C2 and complete a sepurate condition poze for each additional Dresent effecL

0“.4 “Is+ !1,,.1 (.*.!*)

Ask 3S if there is an impairment [refer to Cwd CP2) or any of the following entries in 3b-f:

Ab,e.,s D..*E8 Palsy

Acha (....,1 h..i s.●*.) G.sw,h P.ml”.1*

SI*OA r“, (.X..P -.”. IIL-11 HemwdIow R.plu”

B1.,d .1.1 I. f..,ial E,”(mS*)

m.11 l“1l . . ...3.. S,iltbm..)

c.”.., N.u,.l@s T.mw

Cmmp. (..<.,1 -.”.l -1) N.urill, Ule..

%, Per. V.,le..o “01.s

W..k[n.,s)

S. Whet part .f th. body is .ff.ctod?

Specify

Show the folloning detail:

H..i . . . ..sk.ll..-$. $...

S*. U*pl../rtrkrkr.. . . . . . . . ..ep=r, falJ41., la-r SIB. . . .. I*$*-.W Ea . . . . . . [.-, W ..1.., 1.1,. .i,hl, ., b.h EM* . . . ..l.ltrl+t. -koth Awn. . . . . . . ,hould.r, uppr, ●lk+% 1-., ● -,1s1; W. rl,hl, ., bs!k Hand . . . . . .nllro knd m finq.rs o.ly; Wt. cl~,. ^●r both L*,. . . . hzp, “pp., k..., 1...,, . .●“M.; {.1*, .I,ht. . . belt!

Fe., . . . . .“1!” 1..1. *,4, u 1... ..1”, {.1,, rlghl, . . b.tll

_________________________________

~---Except for eyes, ears. or tntemol organs. ask 3h If there ore any of the

---following ●ntries in 3b-f:

I. I.. NO” SM9 SW.”*S*

h. Whet port .f k (part of budy in 3b- ) i. affcctd by *h. [in f.ctionl sor.ls.r.n.ss] - the skin, IIIUS.1*, II*, or sore* .Ih.r part?

Ask If there ore any of the following entries in 3b-f:

T“m., ‘=71* Growl!!

4. IS this f3wn.t/.yst/gt.wt fi2 mmlig...t . . b.nlgm?

I❑MallznMt z❑ BuIl~ SOOK

[

a. Wh.n was -- (condition in 3b/3

, U 2.wk. ref. r,d.

first netic.d? 2 U Over 2 w-k, !. 3 months

5 --- --- , Ig over 3 rnonels w 1 Year b. Wh.n did -- (mne of iniwv in a I-J 0“,, I ye.r t. 5 year$

W s O OV= 5 ye-s

Askodes as necesscfv:

(W.s”N.. . . since (first date of 2-week ref. DeriodJ .: W.S it Msr. that date?)

(VI.s it 1.ss the. 3 months or more Nw. 3 months ago?) (W., it 1.ss than 1 Y..,., m-. the, 1 Y.., ago?)

(W.. ithSS than 5Y..,. e, me,. *h.. 5 v..,. o-?)

K1 z-b

b.

mn NMI. (K?) —%’s

7. DWIIIS ik.sc 2 wnka, h.w ❑.ny &y. iid -- sw h M f., mu. fkca h.if of fh doy be... of thisc.nditi..?

00❑N... — M.

Ask if““WdVb’” boxmarked in Cl:

8. Durinsk,. 2Wall,, h.W many days did -- miss mom tk half.f fh. day from -. iob .r kusi..ss hcavs. .f this ..nditi..?

00I-JWI.

—D?-Ask if age 5-17:

9. Owl”, h,. 2W+,, h.” many days/id -- miss m@r. h“ fdf ●f If), dq fmm scfd kc-s. .f this ..ndiIIoa?

00❑Nm. —%.

❑Condition h.s ‘-CL LTfV, I. Cl .s sour.. (10)

K2

❑Cmdltic.n ,..s . . . ha.. ‘CL LTR-* ,. C2 as source(K.) 10. Akwt how many ky.

i...

(I2 nth at ) . y“, -q., h.. tki.

.onilti..k.,+-- ,. bodmor.-hdq? ,,..,.,.,.,s WM. .“ .V.mi,ht ptimt im sh.apitd.)

00o❑Non. _ D*Y*

Il. Was -- ●vw h.spl!.lizcd far -- (condition In3b)?

tn-f..

—

Znu.

—

❑Missing .xtr.micy or .rgmn (K4)

❑Oth” (12)

%.Dw, -- still km AIS .Wdl,i.n?

1❑Y.S (K4) ❑No

b.iIAl.-ZJ.iiiti;-&-l;Li;;.;iiit-~il;im-L;gJ.-Rfi---”

z❑C.-d ,❑Oth.r Ispsc/*)J

s❑Und+r ccatml (K4)

(K4J fnve this edition M,,. ii W*’ ~.d?

c.i-Li-GGi&-ili n---"

I❑Y.. ZDN.

9❑Net m●c.ldantiinjury (NC) K4 %❑Ftr.t.c.ldonuini”ry for *IS p.r*m,f4,

a❑06., (13)

M“,s., ,,”,, ,4+4.,

13. IsW. (Sonditfon i.W tk. v.s.h .f &. s-. . ..id..t y.. .Irndy told❑. .kt?

❑Yes(Rccwd W,ldltlm qs nlmb+rwhom

●calc’+nt

qwsflons f

w cenphfcd.)

-❑N.

z ‘NC’

14. Wb.,. did the ecd..t FI.WUI?

t n Athem. (1”.id. ho.%.) z D At hem.(ad,~ex Pranis.s)

3❑ Str,.t md hl’hway (i.clud.s r..dw,y ●nd public sidewalk) 4 n l=”.

s ~ lndu,trl,l place(includes P,mmis.s) . = =.01 (lnclud*. 91,.7 !8S.S)

7 D PI-* of ,*-*-{0. -d SPOttS.●XC9PI .1 achuol 8❑OdIcr (Smc/fyJ

Mark box ;f under 18, ~Under 18 (16) 1%. W.. -- ““do, 18Wk.” .o..id.r,t bopped?

t n Y.S f16j n N.

---b. Was --.1. IFI. Armed Fe,.os when !k. .cctd.nt hoppwd?

2❑Y.*S(18) ❑No

---c. Was -- at work at -- lob o, bush+.,, Wh.” tk. atcidoni ho-wd?

..—

3I-JY.,

4“0No

16.. W., e ..,, hucb, k!,, ., dk., meter VOflid. inv.lv.d

i“ h

wcldont ill ●ly way?

t❑Y.* z❑No (17)

b.~;;;~;-~;.-.;~

j~-i;~-i~~l~~?---I❑Y*S 2DN.

--- .

c.we. [it/* ifh*r .“.] movi”, et** tire.?

t n Y.* zCINo

—

17.. At lk. tire. .f tk. .ccid..t what part of lke bodyW8Shwl?

What kind of lmiuq w., it?

An flhiW .IS.?

P.it(s) 04 u“ * I Kind .1 {.i.v

* Enter pan of Lmdy in same detail ●s for 3;.

** [f ~uItIpIe present ●ffects, enter in C2 each one that is not *C sam as 3b or C2 and complete a separate condition page fof if.

L, DEMOGRAPHIC BACKGROUND PAGE I

LI Refer to .8..

10. Did -- EVER s.rv. on active d.ty i. th. Atm.d Fore.s of th. Unitd Slat..?

b. Wh.n did -- smve?

{

Vietnam Era (Auz. ’64 to April ’75) . . . . VN

Mark box in descending order of priority. Korean War (June .30 t. Jam ’55) KW

Thus, if person served in Vietnam .ond inKorea, World War II (Sepz. ,42 m July 047). ., WWII

mark VN. World War I (April ,!7to Nov. ,18) . . . . . WWI

Post Vietnam (May “75 to present) . . . . PVN Other Service (all other periods) . . . OS .

---G We. -- EVER an activ. membar of a NaNonal Guard co militmy r.s.tv. unit?

I --- --- ---

---d. WasALL of -- .activ. duty s.rvic. r.latcd to 140tlon.1 Guord or military r.s.rv. training?

2.. What ii th. hish.st grad. or y.ar of r.gular school -- ho.●v.r efi*.d.d?

--- ---

---b. Did -- finish th. (number in 2.) l@d./y.arI?

Hand Cord R, Ask first oltematwe for first person; asksecond alternative for other persons.

Ilfmt Is --r...?

30, hot 1$ tho numb.r of fh. group .r gtoups which r.pr.sents -- Inc.?

1 Circle 011thatOPPIY

I - Aleut, Eskimo. or American Indian 4- Whk

7, - Asia” or Pacific Islander S - Another croup not I#sted - Specify

3- Black

--- --- .

Ask of mult,ple entries:

b. Which of thes. groups; Ihat is, ($ntries in 30) w.uld you soy BEST t.pr.s..ts -- m..?

--- --- ---

---c. Mark observed race of respondent(s) only.

I

Hcmd Card O.

40. Are ony ef lhos. groups -- national otlgl. or anc.stry? (Wh.t. did -- .mc.seers cm. from?)

--- ---

---b.P1.awglY. m. the numb.r of tb.greup.

Circle all that apply

I - Puerto Rican 5- Chicano

2- Cuba” 6- Other Latin American

3- Mexican/Mexican.a 7- Other Spanish

4- Mexi.a” America,.

.O”M .!s.1 !,0,21 ,4.,.,2,

Ti

1..

---b.

---..

2..

—

30.

---..

—

40.

—

G Under 5 (NP) G5-17 (2}

I-J 18 .M over (r) t❑Yes (Mark ,.AF.. L.3x, THEN It 2❑No (2)

!(_JVN 5 u PVN

zUKw 000s

>Dwwll 9~DK

4u W*I

❑Ye, 2UNO(2) 7~DK(2J

--- ---

-,@Yez ,nNo ,UDK

,0 c1Never attendedw kmdwlar,en (NPJ Elem: 12345678

H,dx 9 10 II 12 CO,!.*O: 1 2 3 4 5 6.

---,Uy=~ ZUNO

1134

‘J

specify ---

---1234

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--- Swcw

---*OW 206 3(-JO

,

UY.S ,DNo(NP) --- --- . . .

----1234567

L. DEMOGRAPHIC BAcKGROUND PAGE, Canti..cd

L2

Refer to ‘“A,e”” .nd ‘Wo/Wb’. tom. in c,.

Ea. ~~i.r yeu soid that -- has e ieb w busln.ss but did not wock last w..k w th. w..k b.ferc.

-- leaking f- work w en layoff fceme[.b during k,. 2 w..ks?

--- : --- .

b. &,fi., yew

,mii that --

didm,t hm. . iab S, bu,imss lest w,.k .,th. w..k hfor..

-- looking f,, work or en layoff frem a iob during tlmso 2 weeks?

--- .

e. Which, 100kin, for work w em iOyOff from alob?

5.. E.rlio, ye. sold dmt -- w.rk.d last w..k .r th. w..k below. Askbb.

--- .

b. Fe, ~~ did -- work? Enter nom ofatr$any, business, organizalon, or other employer.

--- .

c.For whomdid--wwk at -- last Eull.iim. civiliw @b or buslm.ss l.stlmg 2 csns.eutfv. wtiks or mor.?

Enter name of comony, tusiness, organization, or otier emPloyer.

---d. tWmt kind .f busin.ss . . indwstiy is this? For ●xample. TV ad rcdie manuf.%turinc. retoil shoe store.

State Laki Dep.xtm.m, farm.

--- .

& What kind of wuk was -- doiws? FM●xample, electrical enlineer, stock clerk, typist, fcrmer.

--- .

f. What w.re -- m.st lmpotfmtt .ctivitl.s .r duti.s at tfwt lob? For example, types, keeps account books.

files, sells cars,ODerates pfintinr press, finishes concrete.

---Complete fmm enlrles in 6t-f. If not clear, ask: .

*. w’s

--An .*PI . . ef . PRIVATE company, ku.rwss or 7

s.lf-employ.J I. OWN ku.lc+ss, pmf.s,tcal I.Jlvld* f- -.s.s, s. f.ry. w .ommls.l..? . . . P wacllc., M Iarm?

A FEDERAL ,.W”W”I ●WI. P.? ............. F II“d farm, ●sk: I* III. buslnc.t i..wpw.wd?

ASTATE’.w,”Mn, .mPlq..7 . . . ..S Y., . . . . A LOCAL ,w.r.m.nt ●ploy”? . . . .L !+a(erl.rm ) . . . .

Werkln, WITHOUT PAY 1. h+ ku.1.,ss Wfmm?. . . . . . . . - NEVER WORKED ., -v.* wmksd .1. Iull.tlrm.

<1”111.. I.b I.sll. g 2 w..k. or mom . . . . I SE

NEV

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