Appendix I I I Questionnaires and flashcards

Book - Of __ boo**

NATIONAL HEALTH INTERVIEW 4. Control number I a--IO ‘ISegment 111--14, ISerial 15-10

SURVEY PSU

SUPPLEMENT BOOKLET I ~ I , 2 0 Female : /

6. Final status of supplement 1 9. oat S”pplement W--60 10. Interviewer identification 61-62 o 0 No SP selected completed Name , Code

Interview t 0 Complete interview (all appropriate pages completedl ? 0 Partial ~ntorv~ew fsome but not a11appropriate m /

I pages completed) lExplain in notesl NOTES NOll lnteWiW#

J 0 Refused fExplain in notest 4 0 SP temporarily absent. no proxy available I 0 SP mentally or physically incapable. no proxy available II 0 Other (Explain in nofesl

CONTACT PERSON INFORMATION 0 Contact information for this family unit already obtained. transcribe when editing. Fill i tem f 5 below, THEN go to HIS- I Household Page or next SOA.

Read to SOA respondant at endof interview -The National Statistics may wish to contact you to obtain additional

11. CO”taot Person name ST 41 I 3-4 15-24 I’ 25-391 I Initial 3. i,,ea,co”P”‘i”“T”“e,nunjber,- , , , , , i&jLast I First 1 Middle

I II I t 0 None 2 0 Refused 9 0 DK 1 12~. Address fhlvmbnrandstreatl 41-65 14. Relationship to Sample Person 16-17

b. City 66-66 state 86-37’ Zip - 38-g6 15. Supplement ending time

I , Code I II I

TRANSCRIPTION FROM HIS-l 3-. 16. Area codeltslephane number from HIS-l. item 11 123--32 17b. Mailing address from HIS-l, item 6b t q SameasGaonHIS-1 6

Number and street e-30

1 17a. Exact address from HIS-l, item 6a fPfeaseprkttitems 17a-CJ 31-58 City J’--6O’State 61-52’ zip 53-w

Number and street/description II

, I

Code

I II I

city 53-73’state 1 79-801 zip w c. Special Place name fFiNif appficablel e 1 j Code I I

SUPPLEMENT ON AGING SAMPLE SELECTION Use Table A or 6 as indicated on HIS-1 Household Composit ion Page. Circle that letter and enter number below to indicate the order of interview ft = down RT 64 from the top of the listing, 2 = up from the bottoml. Follow this order whenever two or more sample persons are at home at the same time. 3-4

16. Are there any nondeleted persons 65 yea,s old I1 1 0 Yes llist by age loldest to youngestl in upperportion of appropriate table, )

or older in the family? I mark “9” box on HIS- 1 for each, THEN 19,

10. Are there any nondeleted persons 55-64 years i I 0 Yes (List by age loldest to youngest, in lo~erportion of appropriate table, mark “SF box on ( old In the family? HIS-f for sech “X”person, and begin supplement using the appropriate “order of interview”l

2 0 No IBeain interviewlsJ usino the amxo.wiate “order of interview”l

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