Form 0920-0214 Main Re-Interview Questionnaire

Attachment 6a - Main Reinterview Questionnaire
Form Approved OMB Number 0920-0214 Expires: xx/xx/20xx
Assurance of confidentiality – We take your privacy very seriously. All information that relates to or describes
identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.
NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of
the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C.
242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public
Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is
subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY
identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of
2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks
by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security
weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may
be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the
government.
Notice – Public reporting burden of this collection of information is estimated to average 5 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS
D-74, Atlanta, GA 30333. ATTN: PRA (0920-0214).

2017 NHIS Reinterview Instrument Screens
Survey Response Analysis Branch
Demographic Statistical Methods Division

This document contains all screens in the NHIS 2017 reinterview instrument. Since this
instrument is based on the generic reinterview instrument, some screens are not applicable to
NHIS (these screens are marked by an asterisk (*)).

Front Section:
Screen RIREASON:
Reinterview Help Menu
Press F8 to proceed to the reinterview.
 1. W hy are you calling me again?
 2. Are you calling everyone or am I just lucky?
 3. Don't you have anything better to do with my tax dollars?
I'm too busy to answer your questions again.
 4. Are you “checking up” on me? I told you the truth the first time you called.
 5. Do I have to answer your questions?
 6. How long will this reinterview take?
 7. I thought you only counted people.
 8. TOLL FREE (800) Telephone Number to Verify Reinterview
 9. Return to Reinterview

Screen RIREF1:
Why are you calling me again?
Like any business, we're interested in maintaining the quality of our product, so we
reinterview a few households who are in the survey to ensure we are efficiently and
accurately collecting data.
 1. Continue
 2. Back to Reinterview Help Menu

Screen RIREF2:
Are you calling everyone or am I just lucky?
We are able to get a reliable measure of data quality by reinterviewing only a small
percentage of the total households interviewed in the survey.
 1. Continue
 2. Back to Reinterview Help Menu

2
Screen RIREF3:
Don't you have anything better to do with my tax dollars?
I'm too busy to answer your questions again.
The National Center for Health Statistics, other federal agencies, and businesses will
use the data to assess the health services people receive. The Census Bureau feels a
strong need for an independent measure of its quality. As a result, we feel that the
results from our reinterview are a wise use of our tax dollars.
 1. Continue
 2. Back to Reinterview Help Menu

Screen RIREF4:
Are you “checking up” on me?
I told you the truth the first time you called.
The purpose of reinterview is not to check up on respondents. In order to ensure that
we are efficiently and accurately collecting data, we reinterview a few households who
are in the survey.
 1. Continue
 2. Back to Reinterview Help Menu

Screen RIREF5:
Do I have to answer your questions?
Your participation in this survey is voluntary. However, the information you provide will
help us to ensure the efficiency and accuracy of our data collection procedures. Like
any business, we’re interested in maintaining the quality of our product.
 1. Continue
 2. Back to Reinterview Help Menu

Screen RIREF6:
How long will this reinterview take?
We expect this reinterview to take about five to ten minutes. We have limited
questions in this survey to those essential to current policy initiatives.
 1. Continue
 2. Back to Reinterview Help Menu

3
Screen RIREF7:
I thought you only counted people.
We also conduct surveys to collect information monthly, quarterly, and yearly, on labor
force, retail and wholesale trade, household expenses, household items, and
education, to name a few examples.
 1. Continue
 2. Back to Reinterview Help Menu

Screen RIREF8:
TOLL FREE (800) Telephone Number to confirm
To verify that I am calling from the Census Bureau, you may call my regional office
(PROVIDE RESPONDENT WITH THE TELEPHONE NUMBER OF THE REGIONAL
OFFICE).
When you call, please provide your name and the following identification number:
0000015.
READ IF NECESSARY:
To verify that the toll free number is legitimate, you may call Directory Assistance on
1-800-555-1212.
 1. Continue
 2. Back to Reinterview Help Menu

Screen H_PURPOSE:
Frequently Asked Questions for the National Health Interview Survey
Press F8 to proceed with the reinterview.
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.

General Information
How was I chosen for the National Health Interview Survey?
W hy not interview the house across the street? Why is my participation important?
I’m not sick – why should I be included in a health survey?
W ill the data be held confidential?
W hy should I provide my social security number?
How are the National Health Interview Survey data used?
Address for Survey Comments
Return to Reinterview

4
Screen H_PURPOSE1:
General Information
The basic purpose of the National Health Interview Survey is to obtain national
information about the amount and distribution of illness, its effects in terms of
disability and chronic impairments, and the kind of health services people receive.
 1. Continue
 2. Back to original FAQ list

Screen H_PURPOSE2:
How was I chosen for the National Health Interview Survey?
Every week about 1,400 addresses are chosen by scientific sampling methods to serve
as a cross section of the entire United States. The people at those addresses are
interviewed to obtain information used to describe the health of all Americans.
 1. Continue
 2. Back to original FAQ list

Screen H_PURPOSE3:
Why not interview at the house across the street? Why is my participation important?
We cannot change another address for yours. Scientific sampling methods do not
permit the substitution of another address for those originally selected. It is important
that the people living in the address selected be a part of the survey in order to provide
the most accurate picture of the country’s health.
 1. Continue
 2. Back to original FAQ list

Screen H_PURPOSE4:
I’m not sick – why should I be included in a health survey?
This is a survey of the nation’s health. Health is often described as people who are not
sick. We want to know how many people are sick and why they are sick, but it is also
important to know how many people are healthy and why they are healthy. These
answers will help keep the nation healthy.
 1. Continue
 2. Back to original FAQ list

5
Screen H_PURPOSE5:
Will the data be held confidential?
All information collected in this survey that would permit identification of any
individual or any other business will be held in strict confidence. This information is in
accordance with Section 308(d) of the Public Health Service Act (42 United States Code
242m (d)). We will not release information that could identify you or your family
without your consent. If any federal employee or contractor gives out confidential
information not authorized by law, he or she can be fired and fined and/or imprisoned.
 1. Continue
 2. Back to original FAQ list

Screen H_PURPOSE6:
Why should I provide my Social Security Number?
We would like to know your Social Security Number so we can obtain information that
you have given to other government agencies. The information will be used to conduct
research on issues related to health. This will help us avoid asking questions for
which information is already available. It will also help ensure the accuracy and
completeness of survey results, and help us recontact you, if necessary. We will
protect any information we obtain about you from these agencies from unauthorized
use just as the survey responses are protected. Providing this information is
voluntary, and is collected under the authority of the Public Health Service Act. There
will be no effect on your benefits if you do not provide it.
 1. Continue
 2. Back to original FAQ list

Screen H_PURPOSE7:
How are the National Health Interview Survey data used?
NCHS was authorized by Congress in Section 306 of the Public Health Service Act to
conduct this survey and to produce health information for the nation. Government
agencies, universities, private health planners, and researchers use the data to identify
and work on significant health problems. The data are also used to determine how
best to use available dollars and personnel to solve these health problems.
 1. Continue
 2. Back to original FAQ list

6
Screen H_PURPOSE8:
Address for Survey Comments
If you have any comments about this survey, please send them to:
CDC/ATSDR Reports, Clearance Officer
Paperwork Reduction Project (0920 – 0214)
1600 Clifton Road, MS D-74
Atlanta, GA 30333
 1. Continue
 2. Back to original FAQ list

Screen FIN:
THIS CASE IS NOT COMPLETED.
Enter 1 to continue.
 1. Continue

Screen OMB_NOTICE:
OMB No. 0920-0214: Approval Expires XX/XX/20XX
National Health Interview Survey (NHIS) Reinterview
Read the NOTICE statement to the respondent only if she/he has a serious grievance and
would like to make a complaint regarding the survey. Allow the respondent in this situation to
copy the agency titles and addresses listed in the NOTICE statement. Otherwise, continue
with the reinterview.
NOTICE – Information contained on this form which would permit identification of any individual
or establishment has been collected with a guarantee that it will be held in strict confidence, will
be used only for purposes stated for this study, and will not be disclosed or released to others
without the consent of the individual or establishment in accordance with Section 308(d) of the
Public Health Service Act (42 USC 242m) and the Confidential Information Protection and
Statistical Efficiency Act (44 USC 3501 note). Public reporting burden of this collection of
information is estimated to average about five minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports, Clearance Officer; Paperwork Reduction Project
(0920-0214), 1600 Clifton Rd., MS D-74, Atlanta,GA 30333.
 1. Continue

7
Screen START:
[Fill: SURVEY_NAME]
CAPI Quality Control Reinterview
Date: [Fill: RIDATE]

Time: [Fill: TIME_C]

Reinterview Case Status: [Fill: OUTCOME and OUTCOME’s description]
Original Interview Date: [Fill: INTDATE]
Original FR Code Name: [Fill: ORIFR] "-" [Fill: FR_NAME]
Original Outcome:
[Fill: ORIOUT and ORIOUT’s description]
[Fill: TYPEA_SP / TYPEB_SP / TYPEC_SP /blank]
Original Respondent Name: [Fill: RESPNAME]
Sample Unit Phone: ([Fill: AREA]) [Fill: PREFIX]-[Fill: SUFFIX], ext.[Fill:EXTN] ([Fill:PHTYPE])
[Fill: "Second Phone:" SPHONE (SPHTYP) / blank]
Sample Unit Address: [Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]
[Fill: "Best Time to Contact:" BESTTIME’s description / "Best Time to Contact:" BESTTIM2 /
blank]
[Fill: "Or" BESTTIM2 / blank]
[Fill: “DO NOT call on Sunday” / blank]
[Fill: “Spanish speaking” / blank]
 1. Continue
 2. Quit - Attempt later

Screen START_1A:
CONTACT PERSON INFORMATION
Name:
Title:
Phone:
Address:

[Fill:
[Fill:
[Fill:
[Fill:

CPNAME]
CPTITL]
CPPHON], ext. [Fill: CPEXT] ([Fill: CPPHT])
CPADD1]
CPADD2
CPPO, CPST CPZP5-CPZP4]

[Fill: “NO CONTACT PERSON INFORMATION IS AVAILABLE” / blank]
Enter 1 to continue.
 1. Continue

8
Screen START_1:
Original CAPI Notes
Press Shift-F12 to access original CAPI notes any time during reinterview.
Reinterview Notes
Press Ctrl-F7 to access reinterview notes any time during reinterview.
Enter, view, or update notes as necessary.
Enter 1 to continue.
 1. Continue

Screen HHCOMP:
? [F1]
Line No.
[Fill:
LNO]

Name
[Fill:
FNAME LNAME]

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

Press Shift-F1 to access this screen at any time during the reinterview.
Enter 1 to continue.
 1. Continue

Screen BY_OBS:
The (S)FR determined the original outcome by observation. No contact person information
was collected.
Enter 1 to continue.
 1. Continue

Screen METHOD:
Choose one of the following options to continue:
 1.
 2.
 3.
 4.
 5.

Telephone Reinterview
Personal Visit Reinterview
Quit - Attempt later
Reinterview Noninterview
RO/HQ Discretion - Type A (Contact Supervisor)

9
Screen DIAL:
Respondent Name: [Fill:
Respondent Address:

/
Contact Name:
Contact Address:

[Fill:
[Fill:

RESPNAME]
[Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]
CPNAME]
CPADD1
CPADD2
CPPO, CPST CPZP5-CPZP4]

Dial this number:
([Fill: AREA]) [Fill: PREFIX]-[Fill: SUFFIX], ext. [Fill: EXTN] ([Fill: PHTYPE]) /
[Fill: CPPHON], ext. [Fill: CPEXT] ([Fill: CPPHT])
 1.
 2.
 3.
 4.

Someone answers
Enter new telephone number
Reinterview Noninterview
Quit - Attempt later

Screen _INTRO_:
Enter 1 to update the telephone number.
 1. Update telephone number

Screen NEWNUMBER_A:
Record new number.
In Area Code: [Fill: AREA]
Edit area code or press Enter for same.
New Number: [Fill: PREFIX]-[Fill: SUFFIX]
EXT: [Fill: EXTN]

Screen NEWNUMBER_P:
Record new number.
In Area Code:
New Number:
EXT:

[Fill: NEWNUMBER_A]
[Fill: PREFIX]-[Fill: SUFFIX]
[Fill: EXTN]

Edit prefix or press Enter for same.

10
Screen NEWNUMBER_S:
Record new number.
In Area Code: [Fill: NEWNUMBER_A]
New Number: [Fill: NEWNUMBER_P]-[Fill: SUFFIX]
EXT: [Fill: EXTN]

Edit suffix or press Enter for same.

Screen NEWNUMBER_E:
Record new number.
In Area Code:
New Number:
EXT:

[Fill: NEWNUMBER_A]
[Fill: NEWNUMBER_P]-[Fill: NEWNUMBER_P]
[Fill: EXTN] ♦ Edit extension or press Enter for same.

Screen NEWNUMBER_CP:
Record new number.
New Number: [Fill: CPPHON]
EXT: [Fill: CPEXT]

♦

Edit phone number or press Enter for same.

Screen NEWNUMBER_CE:
Record new number.
New Number: [Fill: NEWNUMBER_CP]
EXT: [Fill: CPEXT] ♦ Edit extension or press Enter for same.

Screen _END_:
Enter 1 to go back to Dial screen.
You may have to press Enter twice to update the phone number entries.

Screen CKSUP:
Contact your supervisor for authorization before conducting a personal visit.
 1. Personal visit reinterview authorized
 2. Quit - Attempt later

11
Screen HELLO_TC:
Hello, I'm ... from the U.S. Census Bureau.
May I speak to [Fill: RESPNAME]?
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.

This is correct person, or correct person called to the phone.
Person not available now. Call back later.
Person cannot be reached. Speak with another household member.
Person unknown at this number.
Person no longer lives there.
Person deceased.
Person can be reached at another number.
Reinterview Noninterview.

Screen HELLO_TCX:
Hello. This is ... from the U.S. Census Bureau.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted
your household.
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or another household member answer a few questions to help us evaluate the
interviewer’s work?
 1. Yes
 2. No
 3. Inconvenient time. Try again later.

Screen VERTELE:
Have I reached area code [Fill: (AREA) PREFIX-SUFFIX, ext. EXTN] /
[CPPHON, ext. CPEXT]?
 1. Yes
 2. No
 3. Refused to verify

12
Screen INTRO_TC:
Thank you for helping us recently by answering questions about
[Fill: CONTACT_C_INFO1] [Fill: CONTACT_C_INFO2].
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Is your address:

[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]?

 1. Yes
 2. No
 3. Refused to verify address

Screen WRNUM:
I'm sorry. I must have dialed incorrectly.
I'll try again.
Enter 1 to go back to Dial screen.
You may have to press Enter twice to go back to Dial screen.
 1. Redial

Screen REFNUM:
I'm sorry. I'll dial again to be sure I've dialed correctly.
 1. After several attempts, wrap up case.
 2. Redial

Screen HELLO_TN:
Hello, I’m... from the U.S. Census Bureau.
May I speak to [Fill: CPNAME]?
 1.
 2.
 3.
 4.
 5.
 6.
 7.

This is correct person, or correct person called to the phone.
Person not available now.
Person unknown at this number
Person no longer lives there.
Person deceased.
Person can be reached at another number.
Reinterview Noninterview

13
Screen VERTYPEA:
This case was a Type A in the original interview.
Please use any available resource to check that the original outcome was:
[Fill: ORIOUT’s description] [Fill: “-” TYPEA_SP / blank] on [Fill: INTDATE].
 1.
 2.
 3.
 4.

Original outcome was correct.
Original outcome was incorrect.
Reinterview Noninterview.
Quit - Attempt later.

Screen HELLO_TNX:
Hello. I'm ... from the U.S. Census Bureau.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted
your location to verify the status of:
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or someone else answer a few questions to help us evaluate the interviewer’s
work?
 1. Yes
 2. No
 3. Inconvenient time. Try again later.

Screen INTRO_TN:
Thank you for recently helping us verify the status of:
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Enter 1 to continue.
 1. Continue

14
Screen HELLO_PC:
Hello. I’m ... from the U.S. Census Bureau.
Here is my identification card.
Show ID card.
May I speak to [FILL: RESPNAME]?
 1.
 2.
 3.
 4.
 5.
 6.
 7.

Correct person available.
Person not available now.
Person unknown at this address.
Person no longer lives there.
Person deceased.
No one lives at this address.
Reinterview Noninterview.

Screen HELLO_PCX:
Hello, I'm ... from the U.S. Census Bureau.
Here is my identification card.
Show ID card.
Our records show that one of our interviewers, [Fill : FR_NAME], recently contacted
your household.
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or another household member answer a few questions to help us evaluate the
interviewer’s work?
 1.
 2.
 3.
 4.

Yes
No
Inconvenient time. Try again later.
No one lives at this address.

Screen INTRO_PC:
Thank you for helping us recently by answering questions about your health, your
family’s health, and health insurance coverage for you and your family.
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Is your address:

[Fill:

 1. Yes
 2. No
 3. Refused to verify address

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]?

15
Screen HELLO_PN:
Hello. I’m... from the U.S. Census Bureau.
Here is my identification card.
Show ID card.
May I speak to [Fill: CPNAME]?
 1.
 2.
 3.
 4.
 5.
 6.

Correct person available.
Person not available now.
Person unknown at this address.
Person no longer lives there.
Person deceased.
Reinterview Noninterview.

Screen HELLO_PNX:
Hello, I’m... from the U.S. Census Bureau. Here is my identification card.
Show ID card.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted this
location to verify the status of:
[Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or someone else answer a few questions to help us evaluate the interviewer’s
work?
 1. Yes
 2. No
 3. Inconvenient time. Try again later.

Screen ADDVER:
I need to verify that the address [Fill: “here” / “there”] is:
[Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4 /
CPADD1
CPADD2
CPPO, CPST CPZP5-CPZP4]
 1. Same address.
 2. Not same address.
 3. Refused to verify.

16
Screen INTRO_PN:
Thank you for recently helping us verify the status of:
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Enter 1 to continue.
 1. Continue

Screen VERBYOBS:
The (S)FR determined the original outcome by observation.
Please use any available resource to check that:
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

was [Fill: ORIOUT’s description] [Fill: “-” TYPEB_SP / “-” TYPEC_SP / blank]
on [Fill: INTDATE].
 1.
 2.
 3.
 4.

Original outcome was correct.
Original outcome was incorrect.
Reinterview Noninterview.
Quit - Attempt later.

Screen HHMEM:
Perhaps you can help me.
Are you a household member [Fill: “who is” MIN_AGE “years or older” / blank]?
 1. Yes
 2. No

Screen HHMEM2:
Is there a household member present I may speak to [Fill: “who is” MIN_AGE “years or
older” / blank]?
 1. Yes
 2. No

17
Screen PROX_C:
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted
your household.
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or another household member answer a few questions to help us evaluate the
interviewer’s work?
 1. Yes
 2. No

Screen PROX_N:
Perhaps you can help me.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted this
location to verify the status of
[Fill: ADDRESS1/
ADDRESS2/
ADDRESS3/
ADDRESS4].
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or someone else answer a few questions to help us evaluate the interviewer’s
work?
 1. Yes
 2. No

Screen PROX_UC:
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted
your household.
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or another household member answer a few questions to help us evaluate the
interviewer’s work?
 1. Yes
 2. No
 3. Inconvenient time. Try again later.

18
Screen PROX_UN:
Perhaps you can help me.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted this
location to verify the status of
[Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4].
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Can you or someone else answer a few questions to help us evaluate the interviewer’s
work?
 1. Yes
 2. No
 3. Inconvenient time. Try again later.

Middle Section:
Screen RIRESP:
? [F1]
Line No.
[Fill: LNO]

Name
[Fill:
FNAME LNAME]

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

Ask if necessary With whom am I speaking?
Enter line number of person you are speaking to or (0) if person is not on roster.

Screen CONTACT_C:
Did an interviewer contact you on or about [Fill: INTDATE] and ask questions about
your health, your family’s health, and health insurance coverage for you and your
family?
 1. Yes
 2. No

Screen ORMODE:
Did the interviewer visit in person or call on the telephone?
 1. Personal visit only
 2. Telephone call only
 3. Both - Interviewer visited and called

19
Screen POLITE:
Was the interviewer polite and professional?
 1. Yes
 2. No

Screen PO_NOTES:
Enter comments from the reinterview respondent here.

Screen LENGTH_H:
About how long did the interview last?
hours

minutes

Screen LENGTH_M:
About how long did the interview last?
1 hour

30_ minutes

Screen LAPTOP:
Did the interviewer use a laptop computer?
 1. Yes
 2. No

Screen ROSTER_1:
? [F1]
Line No.
[Fill: LNO]

Name
[Fill:
FNAME LNAME]

Our records indicate that
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

on [Fill: INTDATE].
Is this correct?
 1. Yes
 2. No

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Read above name(s) in blue

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

was/were living or staying at

20
Screen ROSTER_2:
? [F1]
Line No.
[Fill: LNO]

Name
[Fill:
FNAME LNAME]

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

Enter the line number of the household member(s) (above name(s) in blue) who
wasn’t/weren’t living or staying at the household on [Fill: INTDATE].

Screen ROSTER_3:
? [F1]
Line No.
[Fill: LNO]

Name
[Fill:
FNAME LNAME]

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

Have I missed any household member who
doesn’t have a usual residence elsewhere,
wasn’t away at college or trade commercial school,
is a seaman, or
is a member of the Armed Forces usually sleeping at home?

-

 1. Yes
 2. No

Screen ROSTER_4:
? [F1]
Line No.
[Fill: LNO]

Name
[Fill:
FNAME LNAME]

Relationship
[Fill: REL]

Age
[Fill:
AGE]

Sex
[Fill:
SEX]

Race
[Fill:
RACE]

Type of Resp.
[Fill: HHSTAT2
HHSTAT4 HHSTAT6]

Enter the name of each missing household member who

-

doesn’t have a usual residence elsewhere,
wasn’t away at college or trade commercial school,
is a seaman, or
is a member of the Armed Forces usually sleeping at home?
Press Enter after each name and again after last name to continue.

Screen PROX_PRESENT:
Were you present during the original interview?
 1. Yes
 2. No

21
Screen CKANCEST:
Is [Fill: “your”/ FNAME LNAME“’s”] national ancestry Puerto Rican, Cuban,
Mexican/Mexicano, Mexican American, Chicano, other Latin American, or other
Spanish?
 1. Hispanic
 2. Non-Hispanic

Screen CKRACE:
What [Fill: “is your race” / “race is [FNAME LNAME]”]?
Read if necessary: White, Black, American Indian, Eskimo, Aleut, or Asian/ Pacific Islander
 1. Black or Asian
 2. Non-Black and Non-Asian

Screen RI_MONTH:
What is your date of birth?
Click on or enter the number that corresponds to the month (1-12).
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
 10. October
 11. November
 12. December

Screen RI_DAY:
What is your date of birth?
Enter the number that corresponds to the day of the month (1-31).
Month: [FILL: RI_MONTH]

Day:

Year:

Screen RI_YEAR:
What is your date of birth?
Enter the four digit year.
Month: [FILL: RI_MONTH]

Day: [FILL: RI_DAY]

Year:

22
Screen HH_1:
Did the interviewer ask you questions about having a cell phone?
 1. Yes
 2. No

Screen FAM_1:
Did the interviewer ask you or someone in your household if anyone in the household
was covered by health insurance or some other kind of health care plan?
 1. Yes
 2. No

Screen FAM_2:
Did the interviewer ask you about the highest level of school that you and other family
members have completed?
 1. Yes
 2. No

Screen FAM_3:
Did the interviewer ask you about the amount of your total family income?
 1. Yes
 2. No

Screen SA1_HEALTH:
Did the interviewer ask you about health conditions such as high blood pressure,
asthma, diabetes, or a cold?
 1. Yes
 2. No

Screen SA2_ALCOHOL:
Did the interviewer ask you…
-

about your use of alcohol?

 1. Yes
 2. No

23
Screen SA2_EXERCISE:
Did the interviewer ask you…
-

how often you exercise?

 1. Yes
 2. No

Screen SA2_DOCTOR:
Did the interviewer ask you…
-

how many times you went to the doctor?

 1. Yes
 2. No

Screen SA3_EMROOM:
Did the interviewer ask you…
-

how many times you went to the emergency room?

 1. Yes
 2. No

Screen SA3_SHOT:
Did the interviewer ask you…
-

whether you received a flu shot?

 1. Yes
 2. No

Screen SA3_SLEEP:
Did the interviewer ask you…
-

how many hours you sleep?

 1. Yes
 2. No

24
Screen SOMEONE_ELSE:
Could the interviewer have spoken to another person at
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4 /
CPADD1
CPADD2
CPPO, CPST CPZP5-CPZP4]?

 1. Yes
 2. No

Screen SPEAKTO:
May I speak to her/him?
 1. Yes
 2. No

Screen CONTACT_N:
Did an interviewer visit or call regarding:
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]?

 1. Yes
 2. No

Screen VACANT*:
Was
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

vacant on [Fill: INTDATE]?
 1. Yes
 2. No

25
Screen STAT_VER*:
Is there someone present I could speak with who could tell me the status of
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

on or about[Fill: INTDATE]?
 1. Yes
 2. No

Screen SPEAKTO2*:
May I speak to her/him?
 1. Yes
 2. No

Screen VACANT2*:
Hello, I’m ... from the U.S. Census Bureau.
Our records show that one of our interviewers, [Fill: FR_NAME], recently contacted this
location to verify the status of:
[Fill: ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]
We’re doing a short quality control check to make sure that our interviewers are
following correct procedures.
Was
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

vacant on [Fill: INTDATE]?
 1. Yes
 2. No

26
Screen STATUS:
Our records show that on [Fill: INTDATE],
[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

[Fill: ORIOUT’s description].
Is this information correct?
 1. Yes
 2. No

Screen STAT_PROBE:
Original Outcome:

[Fill: ORIOUT] - [Fill: ORIOUT’s description]
[Fill: TYPEB_SP / TYPEC_SP / blank]

Original Interview Date: [Fill: INTDATE]
What was the status of [Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

on or about [Fill: INTDATE]?
Enter reported status.
Explain any discrepancy between reported status and original outcome.

Screen STAT_PROB2:
Original Outcome: [Fill: ORIOUT] - [Fill: ORIOUT’s description]
Original Interview Date: [Fill: INDATE]
What was the status of

[Fill:

ADDRESS1 /
ADDRESS2 /
ADDRESS3 /
ADDRESS4]

on or about [Fill: INDATE]?
Enter reported status.
Explain any discrepancy between reported status and original outcome.

27

Back Section:
Screen THANK_SORRY:
I'm sorry. I have the wrong address/telephone number. Thank you for your help.
Attempt to contact the correct household now or at a later time.
Enter 1 to continue.
 1. Continue

Screen THANK_YOU:
Thank you for your cooperation. You've been very helpful.
Enter 1 to continue.
 1. Continue

Screen THANK_REF:
I’m sorry to have bothered you.
Enter 1 to continue
 1. Continue

Screen THANK_NOHH:
Thank you for your help, but I need to speak to a household member. I'll try back later.
Enter 1 to continue.
 1. Continue

Screen APPT:
? [F1]
I'd like to schedule a date to complete/conduct the quality check. What DATE and TIME
would be best to call/visit?
Today is: [Fill: RIDATE].
Enter DATE and TIME
Enter (0) if this is a break-off case.
Enter (1) if you don’t intend to follow up on this case.

28
Screen APPT2:
What DATE and TIME would be best to contact
[Fill: RESPNAME /CPNAME, CPTITL] in order to conduct the quality check?
Today is: [Fill: RIDATE]
Enter DATE and TIME
Enter 1 if you don't intend to follow up on this case.

Screen CBTHANK:
Thank you for your help.
We will call/visit again at the time suggested.
Enter 1 to continue.
 1. Continue

Screen STATUS_RI:
This case is not completed.
Make several attempts to contact respondent/contact person before selecting reinterview
noninterview.
 1. Quit - Complete later
 2. Reinterview Noninterview

Screen RI_BREAKOFF:
What was the MAIN reason for breaking off the reinterview?
 1. Respondent was too busy
 2. Respondent had to leave
 3. Questions were too personal for respondent
 4. Reinterview was too long for respondent
 5. Respondent physically/mentally unable to participate
 6. Dislike/mistrust of the government
 7. Relative did not want respondent to participate
 8. Language problem
 9. Reinterviewer computer error
10. Other

29
Screen RI_OUTCM:
Original Outcome:
Original Interview Date:

[FILL: ORIOUT] - [FILL: ORIOUT’s description]
[Fill: TYPEA_SP/TYPEB_SP/TYPEC_SP/blank]
[FILL: INTDATE].

Was the original outcome correct?
 1. Yes
 2. No
 3. Reinterview Noninterview

Screen NONINT:
Which outcome describes this reinterview case?
 1.
 2.
 3.
 4.

Type A Noninterview.
Type B Noninterview.
Type C Noninterview.
Type D Noninterview - Household replaced by new household since the original interview.

Screen TYPEA:
Which Type A outcome describes this reinterview case?
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.

Unable to complete, bad telephone number.
Unable to locate.
No one home.
Temporarily absent.
Refused.
Language problem.
Respondent can’t remember.
Insufficient partial.
Other Type A - Specify in the Reinterview Notes.

Screen TYPEB*:
Which Type B outcome describes this reinterview case?
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.

Vacant, regular or seasonal.
Vacant, storage of household furniture.
Converted to temporary business or storage.
Unoccupied tent or trailer site.
Unfit, to be demolished.
HH institutionalized or temporarily ineligible.
Entire HH under age [Fill: MIN_AGE].
Temporarily occupied by persons with Usual Residence Elsewhere (URE).
Other Type B - Specify in the Reinterview Notes.

30
Screen TYPEB_ALT:
Which Type B outcome describes this reinterview case?
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
 10.
 11.

Vacant, regular.
Vacant, seasonal.
Vacant, storage of household furniture.
Converted to temporary business or storage.
Unoccupied tent or trailer site.
Unfit, to be demolished.
HH institutionalized or temporarily ineligible.
Entire HH under age [Fill: MIN_AGE].
Temporarily occupied by persons with Usual Residence Elsewhere (URE), regular.
Temporarily occupied by persons with Usual Residence Elsewhere (URE), seasonal.
Other Type B - Specify in the Reinterview Notes.

Screen TYPEC:
Which Type C outcome describes this reinterview case?
 1.
 2.
 3.
 4.
 5.
 6.
 7.

Demolished.
House or trailer moved.
Converted to permanent business or storage.
Condemned.
Deceased.
Moved out of country.
Other Type C - Specify in the Reinterview Notes.

Screen MISC_B:
Which of the following options describes the misclassification of this original Type B
case?
 1. Should have been an Interview or Type A.
 2. Should have been another Type B.
 3. Should have been a Type C.

Screen MISC_C:
Which of the following options describes the misclassification of this original Type C
case?
 1. Should have been an Interview or Type A.
 2. Should have been a Type B.
 3. Should have been another Type C.

31
Screen MISC_VINT*:
Which of the following options describes the misclassification of this original vacant
interview case?
 1. Should have been an Interview or Type A.
 2. Should have been a Type B or C.

Screen MISC_BVINT*:
Which of the following options describes the misclassification of this original Type B case?
 1.
 2.
 3.
 4.
 5.

Should have been an Interview or Type A.
Should have been a vacant interview.
Should have been another Type B.
Should have been a Type C.
Should have been a Type D.

Screen MISC_CVINT*:
Which of the following options describes the misclassification of this original Type C case?
 1.
 2.
 3.
 4.
 5.

Should have been an Interview or Type A.
Should have been a vacant interview.
Should have been a Type B.
Should have been another Type C.
Should have been a Type D.

Screen FALSIF:
[Fill: “Your reinterview indicates the following discrepancies:” code and description of each
code listed in DISCREPANCY array /
“Your reinterview did not indicate any discrepancies.”]
Do you suspect falsification?
 1. Yes
 2. No
 3. Unable to determine

Screen DISCREP_NOTES:
Explain why you do not suspect falsification in the Reinterview Notes now.
Press Ctrl-F7 to access Reinterview Notes.
Enter 1 when done with your explanation in the Reinterview Notes.

32
Screen NSF_RIDISP:
Your reinterview detected multiple discrepancies.
Enter the code of the detected discrepancy which best describes this case.
 ** List of discrepancies **

Screen RO_DISC:
Caution: Obtain supervisor's permission before selecting an option below.
Which of the following options describes this reinterview case?
 1.
 2.
 3.
 4.
 5.
 6.
 7.

Hard to interview original case
More than 50 miles from nearest reinterviewer and no phone number
Observed during the original interview
Personal visit needed, but not authorized
Case management or ROSCO problems - Obtain HQ approval
Sample adjustment - Obtain HQ approval
Other RO discretion - Specify in the Reinterview Notes

Screen NO_DISCREP:
Explain why you suspect falsification in the Reinterview Notes now.
Press Ctrl-F7 to access Reinterview Notes.
Enter 1 when done with your explanation in the Reinterview Notes.

Screen SF_RIDISP:
Your reinterview detected multiple discrepancies.
Enter the code of the detected discrepancy which best describes the primary reason you
suspect falsification.
 ** List of discrepancies **

Screen RINOTES_PRE:
Enter reinterview notes about this case now, or view and edit existing notes.
Press Ctrl-F7 to access Reinterview Notes.
Press Shift-F11 to access Abbreviation List.
Press Shift-F12 to view Original CAPI Notes.
Enter 1 to continue after completing reinterview notes.
 1. Continue

33
Screen READYWRAP:
This case is ready to be wrapped up. After exiting, the case will be deleted from your case
list.
Enter 1 to continue.
 1. Continue

34
Reinterview Instrument Screen Index
_END_, 10
_INTRO_, 9
ADDVER, 15
APPT, 27
APPT2, 28
BY_OBS, 8
CBTHANK, 28
CKANCEST, 21
CKRACE, 21
CKSUP, 10
CONTACT_C, 18
CONTACT_N, 24
DIAL, 9
DISCREP_NOTES, 31
FALSIF, 31
FAM_1, 22
FAM_2, 22
FAM_3, 22
FIN, 6
H_PURPOSE, 3
H_PURPOSE1, 4
H_PURPOSE2, 4
H_PURPOSE3, 4
H_PURPOSE4, 4
H_PURPOSE5, 5
H_PURPOSE6, 5
H_PURPOSE7, 5
H_PURPOSE8, 6
HELLO_PC, 14
HELLO_PCX, 14
HELLO_PN, 15
HELLO_PNX, 15
HELLO_TC, 11
HELLO_TCX, 11
HELLO_TN, 12
HELLO_TNX, 13
HH_1, 22
HHCOMP, 8
HHMEM, 16
HHMEM2, 16
INTRO_PC, 14
INTRO_PN, 16
INTRO_TC, 12
INTRO_TN, 13

LAPTOP, 19
LENGTH_H, 19
LENGTH_M, 19
METHOD, 8
MISC_B, 30
MISC_BVINT, 31
MISC_C, 30
MISC_CVINT, 31
MISC_VINT, 31
NEWNUMBER_A, 9
NEWNUMBER_CE, 10
NEWNUMBER_CP, 10
NEWNUMBER_E, 10
NEWNUMBER_P, 9
NEWNUMBER_S, 10
NO_DISCREP, 32
NONINT, 29
NSF_RIDISP, 32
OMB_NOTICE, 6
ORMODE, 18
PO_NOTES, 19
POLITE, 19
PROX_C, 17
PROX_N, 17
PROX_PRESENT, 20
PROX_UC, 17
PROX_UN, 18
READYWRAP, 33
REFNUM, 12
RI_BREAKOFF, 28
RI_DAY, 21
RI_MONTH, 21
RI_OUTCM, 29
RI_YEAR, 21
RINOTES_PRE, 32
RIREASON, 1
RIREF1, 1
RIREF2, 1
RIREF3, 2
RIREF4, 2
RIREF5, 2
RIREF6, 2
RIREF7, 3
RIREF8, 3

35
RIRESP, 18
RO_DISC, 32
ROSTER_1, 19
ROSTER_2, 20
ROSTER_3, 20
ROSTER_4, 20
SA1_HEALTH, 22
SA2_ALCOHOL, 22
SA2_DOCTOR, 23
SA2_EXERCISE, 23
SA3_EMROOM, 23
SA3_SHOT, 23
SA3_SLEEP, 23
SF_RIDISP, 32
SOMEONE_ELSE, 24
SPEAKTO, 24
SPEAKTO2, 25
START, 7
START_1, 8
START_1A, 7

STAT_PROB2, 26
STAT_PROBE, 26
STAT_VER, 25
STATUS, 26
STATUS_RI, 28
THANK_NOHH, 27
THANK_REF, 27
THANK_SORRY, 27
THANK_YOU, 27
TYPEA, 29
TYPEB, 29
TYPEB_ALT, 30
TYPEC, 30
VACANT, 24
VACANT2, 25
VERBYOBS, 16
VERTELE, 11
VERTYPEA, 13
WRNUM, 12