DEMOGRAPHIC BACKGROUND PAGE, Continued

1q YasfRM~fawbutdcJ

H. CONDITION LISTS 5 AND 6

I.. DEMOGRAPHIC BACKGROUND PAGE, Continued

--- --

--- ---

---

--

Page 154 I7 Series 10. No. 199

I.. DEMOGRAPHIC BACKGROUND PAGE, Continued

.2

Refer to “Age”and “Wa/Wb” boxes in Cl.

L2

ia. Ewlior you said that has 8 Job or bu&wu but dld not work hat week or the week before.

GI

W W looking for work or on Ieyoff from l Job during tbor 2 weeks?

---_-___---_---

___-_---b. Ewilor you said that didn’t have a Job or buslnera last week or the weak beform. b.

ru Yes 2 0 No lNPl

War loowng for work or on layoff from a Job during thou 2 waeks?

_-_--_---

c.Whioh, looking for work or on layoff from a Job? ^C. 1 Cl Lmkim I&I 3nSMh Mb)

18. Ewllw you saM that worked Iaat week or the wmok bmfore. Ask 66.

b. For whom dkl - - work? Enter name of company, business, organization, or other employer.

c.Farwhomdid--workat --~~-tlnuId,orburlcwrrkrtiy)2eo~~m6kror~? ^C.

Entername of company, business, organization, or other employer, or mark “N E V ” or ‘A F ” box in person%column.

_---_-_---d. What kind of burinou or industry is this? For exemple, Nand radio manufacturing, d. ^ldurtry retailshoe store, stste Labor Department, farm.

---__-_-_----If ‘A F ”in 6b/c, mark “A F” box in parson‘s column without asking. 8.

kcuprtion

OAF

u4m

l

.Whatkindofworkw~a doing? For example, electricalengineer, stock clerk, typist, farmar.

---L---~--

t.whrwu8 most Important

l

cthrltlas or duties at that Job? Forexamp/a, types, f, kaeps account books, files, sells cars, operates printing press, finishes concrete.

---__---~---

---e---e-Complete from entries in 6b-f, If not clear, ask: :tsu of worker

g.wu

Q. _LIP _so1

h8~ot~?RlVATEwnvmy,bu8inmor EsfkmWdkOWNbusbn.8,~

20F 6USE

kbtMdudfo?ryw,s8lRY,or-7 . . . P Pt88tfW,~hnn?

AFEWML&nwt&?. ... F 2lSk:fStlW k*kw-p S O S 7OWP

AITATE@cmmmmt~?. ... S 5 ...

S E I

4OL sONEV

...

ALocAL8nvsamu~7.. ... L

WdlhllWlTHOUTPAYhf8mlfvbushw8

CrfMn?

... W P

- ~vfo~~ff~~m~sd at. full-this

... ... ... ..N E V

IOTNOTES

-- --

---

LDEMOGRAPHIC BACKGROUND PAGE, Continued

Mark box if under 14. If ‘Married” refer to household composition and mark accordingly.

7. is now married, widowed, divorced, separated, or haa never been married?

Ba. Was the total combined FAMILY income during the past 12 months - that is, yours, headnames. including ,4rmed Fmembe s /ivins at homcj more or less than s20,000? include money from jobs, social security, retirement Income, :nemployment payments, public assistance, and so forth. Also include incoma from intsrest, dlvldsnds, net income from business, farm, or rent, and any other money Income received.

Readif necessary: income Is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical care servicss or have certain conditions more or less often than those in another group.

-~--_-______-___---_____________________---~-~----Read parenthetical phrase if Armed Forces member living at home or if necessary.

b. Of those income groups, which letter best represents the total combined FAMILY income during the past 12 months (thet is, yours, (read names, including Armed Forces members living at homell? include wages, salaries, and other items we just talked about.

Read if necessary: income Is important in analyzing the health information we collect. For example, this Information helps us to learn whether persons In one income group use certain types of medical care services or have certein conditions more or less often then those in another group.

a. Mark first appropriate box.

___~_______________---~---b. Enter person number of respondent.

Enter person number of first parent listed or mark box.

Enterperson number of spouse or mark box.

)TES

,“M HIS.1119841ICZ43l Page 46

Tg&

3s.

-Ra,

-0 q

^{Under 14}

I 0 Married - spouse in HH 2 [3 Manied - spouse not in HH 3 0 Widowed

4 0 Divorced 5 0 Sewrated

.----OoOA 100 K 200 u

oru B 11OL 21 Cl v

02oc 12oh4 2zow

03clD 130 N 230X

04UE 1400 24‘iY

OSOF 150 P 2502

OSOG 1600 zanzz

07nH 170 R

0801 x30 s

OSOJ tSOT

1q

Present for all questions 2

q

Present for some question!,

3q Notpresent

00q

Nom in hwaelmld

Person number of swse

-- Page 156 0 Series 10, No. 199

I.. DEMOGRAPHIC BACKGROUND PAGE, Continued

L5

L6

Enter date of birth from question 3 on Household Composition pege.

a. In what Stats or country was born?

Print the full name of the State or mark the appropriate box if the person was not born in the United States.

-_---_---_----_---~---~~~----~-~-~-~~~~-~~----If born in US., ask 9b only; if born in foreign country, ask 9c only.

b. Altogether, how many years has lived in (State of present residence)?

c. Altogethsr, how many years has - - lived In the United Statss?

L7

^Wnt full name, including middle initial, from question 7 on Household Composition page.

Veriv for males; ask for females.

IO. What is - - fathsr’s LAST name? Verify spelling. DO NOT write “Same. “

Read to respondent(s): We slao nssd Social Security Number to link with vltel statistics and other records of ths Dspsrtment of Hsshh and Humsn Ssnicss to perform haalth-related research. Provldlng this informstlon Is voluntsry end collected under the authority ofths Public Hsshh Swvice Act. There will be no dfoct on - - henafhs if you do provids it and this number Will not be given to any other government or nongovemment

l

gsncy.

Read if necessary: The Public Health Service Act is title 42, United Stetes Code, section 242k.

Il. What is - - Social Security Number?

L8

Mark box to indicate how Social Security number was or was not obtained.

Pago 48

stats 01 I7 f%wto Rico 06 aCuba 02 Cl Vrgin bbnds 06 chxlca 03

q Guam Q8q ANottw

countrlw 04 0 Canada

---w

q Lsuthsn1yr.

2 0 1 yr., buthm 6

b. ^{3 0} Syrs.,kuthmlO 40 lOyrs..buthm15 50 15yn.ormom s~DK

,,,----,;,*----~

20 lyr.,kuthan5 0. 3 Cl 6yn.,k.dhan10

40 lOym.,bssthmt5 60 lSyrs.armom SnDK Lsst

L7 First b

Middls initbl k

Fathex’s LAST name lb2--7’

IO.

1’2-“’

BssDa9sos 0 DK

cm-m-ma

, , 5acbl SacurltvNumbar

’ M.&if number omaflwd flwm

I 0ElDoesntJt 2 0 Recorda

hrw SSN 7 0 Rsfusod

1 q Memory

1 •I Self-pnoeal 1 2

q

Sslf-te*phona

I.8

3 q

Proxy-parsonal 4 0 Proxy-telephone

L. DEMOGRAPHIC BACKGROUND PAGE, Continued

Read to /-/h/d. respondem: The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the name, address, and telephone number of a relative or friend who would know where you could be reached in case we have trouble reaching you. (Please give me the name of someone who Is not currently living In the household.) Please print items 72- 16.

piei

2. Contact Person name ^3-4 ⁱ ^I26--301 1 40 144. Area code/telephone number (97-1M

Last I=, First I Middle

I initial II

30. Address (Number and street) ^141-66 I 0 None

z 0 Refused sODK

b. City l6e-es, 1

State l36--87/~1p Is*-es- 15. Relationship to household respondent &

II 1Code

6. It you must be contacted again, what Is the best time to cell or visit?

OOTNOTES

In document Current Estimates From the National Health Interview Survey, 1995 (Page 163-167)