National Study on Health and Safety

National Study on Health and Safety
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Household Questions
 Please use a black or blue pen to complete this form.
 Mark  to indicate your answer.
 If you want to change your answer, darken the box

Please answer the following questions for each adult in the household, age 18 years or older. Include yourself as Person 1. If more than five persons, continue on back.
Include adults who usually stay at this address but are temporarily away on business, on vacation, or in a hospital. Do not include college students who live away from home.
4. How many adults age 18 years or older live in this household?

and mark the correct answer.

Person 1

About You
This survey may be completed by any household member
age 18 years or older. Completion of this survey is
voluntary.
Please answer the first questions about your own health
and safety behaviors.

Person 2

(You)

Person 3

Person 4

Person 5

5. What is the person's
first name or initials?

6. Is this person:

1
2

Male
Female

1
2

Male
Female

Male
Female

1
2

1
2

Male
Female

1
2

Male
Female

1. Woul
d 
y
ou 
s
a
y

i
n 
g
ener
a
l

t
hat

y
our

hea
l
t
h 
i
s
…?
Excellent........................................................
Very good......................................................
Good..............................................................
Fair.................................................................
Poor...............................................................

1

years

4
5

8. Is this person
of Hispanic or
Latino origin?

1
2

years

years

years

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

Yes
No

1
2
3
4
5

9. What is his/her race?
You may mark more
than one.

1
2
3
4
5

3. In the last 12 months, have you gone to a hospital
or emergency room because of an injury?
Yes..................................................................
No...................................................................

years

3

2. On average, during the last 12 months, how often
have you ridden public transportation?
Almost every day (or more frequently).........
At least once a week......................................
At least once a month...................................
Less often.......................................................
Never.............................................................

7. What is his/her age?

2

2
3
4
5

2
3
4
5

2
3
4
5

2
3
4
5

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1
2

Please provide us with your name and telephone number in case we need to contact you about this survey.
NAME
Thank you for completing this survey.

TELEPHONE

-

-

 Please continue on back if additional adults live in this household.

Household Questions
Please answer the following questions for each additional adult in the household, age 18 years or older.

OMB 
#
:

x
x
x
x
‐
x
x
x
x
Exp Date: MM/DD/YYYY

Person 6

Person 7

Person 8

5. What is the
person's first
name or initials?
6. Is this person:

1
2

7. What is his/
her age?

8. Is this person
of Hispanic or
Latino origin?

9. What is his/
her race?
You may mark
more than one.

Male
Female

1
2

years

1
2

1
2
3
4
5

Male
Female

1
2

years

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

2
3
4
5

Male
Female

years

Yes
No

1

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

1

2

2
3
4
5

Yes
No

White
Black or African American
American Indian or
Alaska Native
Asian
Native Hawaiian or other
Pacific Islander

All of the information you provide will be kept strictly confidential and not disclosed to anyone but the study researchers.
Return completed survey to Westat, 1600 Research Blvd., RW2634, Rockville, MD 20850
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