CP, YP, YA, YX

L1. CHECK AGE: Is (NAME)'s age....

\<17 01  *Go to L8*

17+ 00  *Continue*

YP, YA, YX

NHIS-D Adult Followback

L2. These next questions are about the place (FILL "NAME LIVES" IF
RTYPE=01, 03; "YOU LIVE" IF RTYPE=02).

> (IF A10=05, NAME IS LIVING AT SCHOOL FILL: Please answer for the place
> (FILL "NAME LIVES" IF RTYPE=01, 03, "YOU LIVE" IF RTYPE=02) when (FILL
> "HE/SHE IS" IF RTYPE=01, 03; "YOU ARE" IF RTYPE=02) not at school.
>
> How long (FILL "HAS (NAME)" IF RTYPE=01,03; "HAVE YOU" IF RTYPE=02)
> been living there?

Estas siguientes preguntas son acerca del lugar donde (FILL "NAME" IF
RTYPE=01,03; "UD." IF RTYPE=02) vive.

(IF A10=05, NAME IS LIVING AT SCHOOL FILL: Por favor conteste acerca del
lugar donde (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) vive, cuando
(FILL "él/ella" IF RTYPE=01,03; "UD." IF RTYPE=02) no está en la
escuela.

¿Cuánto tiempo hace que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
vive allí?

\|\_\_\_\|\_\_\_\| YEARS

LESS THAN A YEAR 0

DON'T KNOW d

REFUSED r

YP, YA, YX

NHIS-D Adult Followback

L3. Is this place a...

¿Es este lugar un(a) . . .

*Read list, code only one*

Single family home 01 *Go to L8*

Mobile home 02 *Go to L8*

Regular apartment 03 *Go to L8*

Supervised apartment 04

Group home 05

Halfway house 06

Personal care or board and care home 07

Assisted living facility 08

Nursing or convalescent home 09

Center for Independent Living 10

Some other type of supervised group

![](media/image1.wmf) residence or facility 11

Something else (SPECIFY) 12

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Casa para una sóla familia 01 *Go to L8*

Casa móvil (Mobile home) 02 *Go to L8*

Apartamento regular 03 *Go to L8*

Apartmento bajo supervisión 04

Hogar de grupo (Group home) 05

Hogar Intermedio (Halfway house) 06

Hogar de Cuidado Personal, o de

Alojamiento y cuidado

(Personal care or board and care home) 07

Hogar o residencia de vivienda asistida

(Assisted living facility) 08

Hogar de Convalecencia

(Nursing or convalescent home) 09

Centro de Vida Independiente

(Center for Independent Living) 10

Algún otro tipo de residencia de grupo o

![](media/image2.wmf) Instalación bajo supervisión 11

¿Alguna otra cosa? (SPECIFY) 12

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (not in mobile/single family home or apartment)

NHIS-D Adult Followback

L4. Does this place primarily or exclusively serve persons with hearing
or vision impairments, mental illness, mental retardation, or
developmental disabilities?

> ¿Sirve este lugar principalmente o exclusivamente a personas con
> impedimentos de vista o del oído, enfermedad mental, retardación
> mental, o incapacidades de desarrollo?
>
> YES 01

NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (not in mobile/single family home or apartment)

NHIS-D Adult Followback

L5. Whether (FILL "NAME USES" IF RTYPE=01,03; "YOU USE" IF RTYPE=02)
them or not, does this place routinely provide services such as meals,
help with housework or personal care, transportation, or recreation?

Si o no los usa (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
¿proporciona este lugar, de rutina, servicios tales como: comidas, ayuda
en quehaceres domésticos o cuidado personal, transporte, o recreación?

YES 01

NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX (not in mobile/single family home or apartment)

NHIS-D Adult Followback (modified)

L6. Who pays for most of the cost for (FILL "NAME'S" IF RTYPE=01,03;
"YOUR" IF RTYPE=02) stay at this place?

PROBE: For example, (FILL "NAME" IF RTYPE=01,03; "YOU" IF RTYPE=02),
(FILL "YOUR FAMILY" IF RTYPE=01, 02; "HIS/HER FAMILY" IF RTYPE=03),
insurance, Medicaid, an employer, or something else?

¿Quién paga la mayor parte de los costos de (FILL "la estadía de (NAME)"
IF RTYPE=01,03; " SU estadía" iF RTYPE=02) en este lugar)?

PROBE: Por ejemplo, (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02), su
familia, su seguro, Medicaid, un empleador, o alguna otra cosa?

(NAME) 01

(NAME'S) FAMILY LIVING IN THE SAME

HOUSEHOLD 02

(NAME'S) FAMILY LIVING NOT LIVING

IN THE SAME HOUSEHOLD 03

INSURANCE/MEDICAID 04

EMPLOYER 05

REHABILITATION PROGRAM 06

SCHOOL SYSTEM/SPECIAL EDUCATION 07

TITLE V PROGRAM 08

NO ONE/FREE 09

![](media/image3.wmf) USE SSI BENEFIT/SSA 10

OTHER (SPECIFY) 11

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

YP, YA, YX (not in mobile/single family home or apartment)

NHIS-D Adult Followback (modified)

L7. In the past 12 months, about how much did (FILL "YOU AND YOUR
FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY" IF RTYPE=03) pay for
(FILL "HIS/HER" IF RTYPE=01,03; "YOUR" IF RTYPE=02) stay at this place,
if any? Do not count any money that has been or will be reimbursed by
insurance or from any other source but include any insurance copayments
(FILL "YOU AND YOUR FAMILY" IF RTYPE=01, 02; "NAME AND HIS/HER FAMILY"
IF RTYPE=03) may have paid.

> En los últimos 12 meses, ¿más o menos cuánto pagaron (FILL "UD." IF
> RTYPE=01,02; "NAME" IF RTYPE=03) y su familia por su estadía en este
> lugar si pagaron algo? No cuente dinero que ha sido, o que será,
> reembolsado por el seguro o de cualquier otra fuente, pero sí incluya
> copagos de seguros (insurance copayments) que (FILL "UD." IF
> RTYPE=01,02; "NAME" IF RTYPE=03) y su familia quizás pagaron.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.00 AMOUNT PAID (\$0-\$9,999)

DON'T KNOW d

REFUSED r

  -----------------------------------------------------------------------
  **G GO TO L17**

  -----------------------------------------------------------------------

CP, YP, YA, YX

SIPP/NSAF (modified)

L8. READ IF AGE=\<17: These next questions are about the place (NAME)
lives.

Is (FILL "YOUR" IF RTYPE=01, 02; "NAME'S" IF RTYPE=03) home or
apartment...

> PROBE: (FILL "DOES YOUR FAMILY" IF RTYPE=01; "DO YOU" IF RTYPE=02;
> "DOES NAME" IF RTYPE=03) own (FILL "YOUR" IF RTYPE=01,02; "HIS/HER" IF
> RTYPE=03) home, rent (FILL "YOUR" IF RTYPE=01,02; "HIS/HER" IF
> RTYPE=03) home, or live there without paying rent?
>
> Ahora le quiero hacer unas pocas preguntas acerca del lugar donde vive
> (NAME).

¿Es (FILL "UNA casa o apartmento" IF RTYPE=01,02; "LA casa o EL
apartmento de NAME" IF RTYPE=03"...

> PROBE: ¿ES (FILL "SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02 ;
> "(NAME)" IF RTYPE=03) dueñode su hogar, la alquila, o vive allí sin
> pagar alquiler o renta?

INTERVIEWER: IF THE RESPONDENT LIVES IN A MOBILE HOME AND PAYS BOTH RENT
AND MORTGAGE, CODE "OWNED."

*Read list, code only one*

Owned or being bought by someone

in the household 01

Rented, or 02

Occupied without payment of

rent? 03

Propiedad suya, o alguien en su hogar

está comprándola 01

Alquilada, o 02

Ocupada sin pagar alquiler o

renta? 03

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (in mobile/single family home or apartment)

L9. CHECK AGE: Is (NAME'S) age...

\<17 01**→** *Continue*

17+ 02**→** *Go to L11*

CP

NSAF

L10. How long have you lived in your home?

¿Cuánto tiempo hace que vive en su hogar?

\|\_\_\|\_\_\| MONTHS \|\_\_\|\_\_\| YEARS

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (in mobile/single family home or apartment)

L11. CHECK: IS L8=01 or 02 (NAME OR NAME'S FAMILY PAYS RENT OR
MORTGAGE)?

YES 01 **→** *Continue*

NO 00 **→** *Go to L16*

CP, YP, YA, YX (in mobile/single family home or apartment)

Created

L12. Did (FILL "YOUR FAMILY" IF RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF
RTYPE=03) pay all of the (FILL "MORTGAGE" IF L8=01; "RENT" L8=02) last
month, did (FILL "YOUR FAMILY" IF RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF
RTYPE=03) share the payment with someone else, or did someone else pay
all the (FILL "MORTGAGE" IF L8=01; "RENT" L8=02)?

> El mes pasado, pagó (FILL "SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02;
> "NAME" IF RTYPE=03) todo (FILL "la hipoteca" IF L8=01; "el alquiler"
> IF L8=02), compartió (FILL "SU FAMILIA" IF RTYPE=01; "UD." IF
> RTYPE=02; "NAME" IF RTYPE=03) el pago con otra persona, o pagó otra
> persona todo (FILL "la hipoteca" IF L8=01; "el alquiler" IF L8=02)?

NAME OR NAME'S FAMILY PAID ALL 01

SHARED 02

SOMEONE ELSE PAID ALL 03**→** *Go to L16*

GOVERNMENT ASSISTANCE PROGRAM 04**→** *Go to L16*

HOME IS PAID FOR 05**→** *Go to L17*

NO ONE PAID 06**→** *Go to L16*

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (in mobile/single family home or apartment)

NSAF

L13. IF L8=01: Altogether, in (LAST MONTH), what was (FILL "YOUR
FAMILY'S" IF RTYPE=01; "YOUR" IF RTYPE=02; "NAME'S" IF RTYPE=03)
mortgage payment?

IF L8=02: Altogether, in (LAST MONTH), what did (FILL "YOUR FAMILY" IF
RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF RTYPE=03) pay in rent?

> PROBE IF L3=02, RESPONDENT LIVES IN A MOBILE HOME: What did (FILL
> "YOUR FAMILY" IF RTYPE=01; "YOU" IF RTYPE=02; "NAME" IF RTYPE=03) pay
> in mortgage and rent last month? Include mortgage and rent for your
> home itself, and the lot, if applicable.

READ IF L12=02: We are interested in knowing only (FILL "YOUR FAMILY'S"
IF RTYPE=01; "YOUR" IF RTYPE=02; "NAME'S" IF RTYPE=03) part of the
payment.

IF L8=01: En total, en (LAST MONTH)¿cuánto fue el pago de la hipoteca de
(FILL "SU FAMILIA" IF RTYPE=01; "UD" IF RTYPE=02; "NAME" IF RTYPE=03)?

IF L8=02: En total, en (LAST MONTH), ¿cuánto pagó (FILL "SU FAMILIA" IF
RTYPE=01; "UD" IF RTYPE=02; "NAME" IF RTYPE=03) de alquiler?

PROBE IF L3=02: ¿Cuánto pagó (FILL "SU FAMILIA" IF RTYPE=01; "UD" IF
RTYPE=02; "NAME" IF RTYPE=03) por su hipoteca, y su alquiler y el mes
pasado? Incluya los pagos de la hipoteca y del alquiler del hogar mismo,
y del terreno, si es aplicable.

> Read if L12=02: Sólo estamos interesados en saber cuál fue la parte
> del pago de (FILL "SU FAMILIA" IF RTYPE=01; "UD" IF RTYPE=02; "NAME"
> IF RTYPE=03).

*If R volunteers that house is paid for, enter 0.*

*If R volunteers that no one paid, or could not afford, enter 0.*

\$\_\_\_\_\_\_\_\_\_\_\_\_ PER MONTH (\$0-\$9,999)

DON'T KNOW d

REFUSED r

CP, YP, YA, YX (in mobile/single family home or apartment)

L14. CHECK L8: Does (NAME AND HIS/HER FAMILY) own the home, rent the
home, or something else?

OWN 01  *Go to L17*

RENT 02  *Continue*

SOMETHING ELSE (03, DK/RF) 03  *Go to L16*

CP, YP, YA, YX (renting, in mobile/single family home or apartment)

SIPP/NSAF

L15. (FILL "IS YOUR FAMILY" IF RTYPE=01; "ARE YOU" IF RTYPE=02; "IS
NAME" IF RTYPE=03) paying lower rent because the federal, state, or
local government is paying part of the rent?

¿Está (FILL "SU FAMILIA" IF RTYPE=01; "UD." IF RTYPE=02; "NAME" IF
RTYPE=03) pagando un alquiler más bajo porque el gobierno federal,
estatal, o local está pagando parte del alquiler?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

SIPP/NSAF

L16. Is (FILL "YOUR" IF RTYPE=01, 02; "NAME'S" IF RTYPE=03) home in a
public housing project, that is, owned by a local housing authority or
other public agency?

¿Está (FILL "SU HOGAR" IF RTYPE=01,02; "EL HOGAR DE (NAME)" IF RTYPE=03)
en un proyecto de vivienda pública, o sea que pertenece a una autoridad
de vivienda local (housing authority) u otra agencia pública?

> YES 01
>
> NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

NHIS-D (Child Followback)

L17. Does (FILL "YOUR" IF RTYPE=01, 02; "NAME'S" IF RTYPE=03) home have
any special features designed to help (FILL "NAME" IF RTYPE=01; "YOU" IF
RTYPE=02; "HIM/HER" IF RTYPE=03) get around the home?

PROBE: This includes things like widened doors or hallways, ramps,
railings, kitchen or bathroom modifications, and alerting devices.

¿Tiene (FILL "SU HOGAR" IF RTYPE=01,02; "EL HOGAR DE (NAME)" IF
RTYPE=03) características especiales diseñadas para ayudarle(a) a (FILL
"NAME" IF RTYPE=01; "UD." IF RTYPE=02; "él/ella" IF RTYPE=03) a moverse
dentro del hogar?

PROBE: Esto incluye cosas tales como puertas o pasillos más anchos,
rampas, pasamanos (railings), modificaciones en la cocina o en el baño,
y mecanismos de alerta.

> YES 01
>
> ![](media/image4.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

NHIS-D (Child Followback)

L18. What special features does this home have?

¿Qué características especiales tiene este hogar?

*Do not read list, code all that apply*

> WIDENED DOORWAYS OR HALLWAYS 01
>
> RAMPS OR STREET LEVEL ENTRANCES 02
>
> RAILINGS 03
>
> AUTOMATIC OR EASY TO OPEN DOORS 04
>
> ACCESSIBLE PARKING OR DROP-OFF SITE 05
>
> BATHROOM MODIFICATIONS 06
>
> KITCHEN MODIFICATIONS 07
>
> ELEVATOR, CHAIR LIFT, OR STAIR GLIDE 08
>
> ALERTING DEVICES 09

![](media/image5.wmf) OTHER (SPECIFY) 10

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

NHIS-D (Child Followback)

L19. (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) have a
**need** for any (FILL "OTHER" IF L17=01) special features to get around
the home?

PROBE: This includes things like widened doors or hallways, ramps,
railings, kitchen or bathroom modifications, and alerting devices.

¿**Necesita** (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) cualquier
(FILL "OTRA" IF L17=01) característica especial para moverse dentro de
hogar?

PROBE: Esto incluye cosas tales como puertas o pasillos más anchos,
rampas, pasamanos (railings), modificaciones en la cocina o en el baño,
y mecanismos de alerta.

> YES 01
>
> ![](media/image6.wmf)NO 00
>
> DON'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

L20. What (FILL "OTHER" IF L17=01) special features (FILL "DOES NAME" IF
RTYPE=01, 03; "DO YOU" IF RTYPE=02) need?

> ¿Cuáles (FILL "OTRAS" IF L17=01) características especiales necesita
> (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)?

*Do not read list, code all that apply*

> WIDENED DOORWAYS OR HALLWAYS 01
>
> RAMPS OR STREET LEVEL ENTRANCES 02
>
> RAILINGS 03
>
> AUTOMATIC OR EASY TO OPEN DOORS 04
>
> ACCESSIBLE PARKING OR DROP-OFF SITE 05
>
> BATHROOM MODIFICATIONS 06
>
> KITCHEN MODIFICATIONS 07
>
> ELEVATOR, CHAIR LIFT, OR STAIR GLIDE 08
>
> ![](media/image7.wmf) ALERTING DEVICES 09

OTHER (SPECIFY) 10

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

Created

L21. Why does (FILL "YOUR" IF RTYPE=01, 02; "NAME'S" IF RTYPE=03;) home
not have the special features that ("HE/SHE NEEDS" IF RTYPE=01, 03; "YOU
NEED" IF RTYPE=02)?

¿Por qué no tiene (FILL "su hogar" IF RTYPE=01,02; "el hogar de (NAME)"
IF RTYPE=03") las características especiales que (FILL "él/ella" IF
RTYPE=01,03; "UD." IF RTYPE=02) necesita?

> *Code all that apply*

CAN'T AFFORD THE MODIFICATIONS 01

NOT ALLOWED TO MAKE CHANGES 02

DON'T KNOW HOW TO MAKE CHANGES/

WHO TO CONTACT 03

NEVER GOT AROUND TO IT 04

![](media/image8.wmf) NOT MY DECISION/LIVE IN GROUP HOME 05

OTHER (SPECIFY) 06

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

L22. CHECK AGE: Is NAME'S age...

\<17 01 *Continue*

17+ 02 *Go to L24*

CP

L23. CHECK: Is K57 =0, DK, RF (no cars are owned by family) and/or
K65=0, DK ,RF (child does not own car)?

YES 01 *Go to Part M*

NO 00 *Go to L27*

YP, YA, YX

NHIS-D Adult Followback

L24. How frequently (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF
RTYPE=02) drive a car or other motor vehicle? Would that be...

¿Con qué frecuencia maneja (FILL "NAME" IF RTYPE=01,03; "UD." IF
RTYPE=02) un carro u otro vehículo motorizado? ¿Sería....

*Read list, code only one*

Everyday, or almost everyday 01 *Go to L27*

Occasionally 02 *Go to L27*

Seldom 03

Never 04

Todos los días o casi todos los días 01 *Go to L27*

De vez en cuando 02 *Go to L27*

Casi nunca 03

Nunca 04

DON'T KNOW d *Go to L27*

REFUSED r *Go to L27*

YP, YA, YX

NHIS-D Adult Followback

L25. Is this because of an impairment or health problem?

¿Es esto por causa de algún impedimento o problema de salud?

YES 01

NO 00

DON'T KNOW d

REFUSED r

YP, YA, YX

L26. CHECK: Is L24=04, that is, (NAME) never drives a car?

YES 01 *Go to L33*

NO 00 *Continue*

CP, YP, YA, YX

NHIS-D (Child Followback)

L27. (FILL "DO YOU" IF RTYPE=01, 02; "DOES NAME" IF RTYPE=03) have any
special equipment on a car or other motor vehicle because of an
impairment or health problem that (FILL "NAME HAS" IF RTYPE=01, 03; "YOU
HAVE" IF RTYPE=02)?

¿Tiene (FILL "UD." IF RTYPE=01,02; "NAME" IF RTYPE=03) algún aparato o
equipo especial en un carro o en otro vehículo motorizado, por causa de
algún impedimento o problema de salud que (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) tiene?

YES 01

NO 00 *Go to L29*

> DON\'T KNOW d *Go to L29*

REFUSED r *Go to L29*

CP, YP, YA, YX

NHIS-D (Child Followback)

L28. What special equipment (FILL "DO YOU" IF RTYPE=01, 02; "DOES NAME"
IF RTYPE=03) have?

> ¿Qué aparato o equipo especial tiene (FILL "UD." IF RTYPE=01,02;
> "NAME" IF RTYPE=03)?

*Do not read list, code all that apply*

> HAND CONTROLS 01
>
> HAND RAILS, STRAPS, SPECIALIZED
>
> HANDLES, RAMPS, OR LIFTS 02
>
> POWER CONTROLS FOR WINDOWS,
>
> MIRRORS, SEAT, OR STEERING 03
>
> AUTOMATIC TRANSMISSION 04
>
> AIR CONDITIONING 05
>
> A BUTTON THAT OPENS THE DOOR 06
>
> ![](media/image9.wmf) A LARGE TRUNK OR STORAGE AREA 07
>
> OTHER (SPECIFY) 08
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON\'T KNOW d

REFUSED r

CP, YP, YA, YX

NHIS-D (Child Followback)

L29. (FILL "DO YOU" IF RTYPE=01, 02; "DOES NAME" IF RTYPE=03) have a
**need** for any (FILL "OTHER" IF L27=01) special equipment or features
on a car or other motor vehicle because of any impairment or health
problem that (FILL "NAME HAS" IF RTYPE=01, 03; "YOU HAVE" IF RTYPE=02)?

> ¿Tiene (FILL "UD." IF RTYPE=01,02; "NAME" IF RTYPE=03) alguna
>
> **necesidad** para algún (FILL "OTRO" IF L27=01) aparato o equipo
> especial

en un carro u otro vehículo motorizado, por causa de algún impedimento o

> problema de salud que (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
>
> tiene?

YES 01

![](media/image10.wmf) NO 00

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

NHIS-D (Child Followback)

L30. What (FILL "OTHER" IF L27=01) equipment or features (FILL "DOES
NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) need?

¿Qué (FILL "OTRO" IF L27=01) aparato especial o (FILL "OTRAS" IF L27=01)
características especiales necesita (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02)?

*Do not read list, code all that apply*

> HAND CONTROLS 01
>
> HAND RAILS, STRAPS, SPECIALIZED
>
> HANDLES, RAMPS, OR LIFTS 02
>
> POWER CONTROLS FOR WINDOWS,
>
> MIRRORS, SEAT, OR STEERING 03
>
> AUTOMATIC TRANSMISSION 04
>
> AIR CONDITIONING 05
>
> A BUTTON THAT OPENS THE DOOR 06
>
> ![](media/image11.wmf) A LARGE TRUNK OR STORAGE AREA 07
>
> OTHER (SPECIFY) 08
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON\'T KNOW d
>
> REFUSED r

CP, YP, YA, YX

Created

L31. Why (FILL "DOES NAME" IF RTYPE=01, 03; "DO YOU" IF RTYPE=02) not
have the special features on a car that (FILL "HE/SHE NEEDS" IF
RTYPE=01, 03; "YOU NEED" IF RTYPE=02)?

¿Por qué no tiene (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) el
aparato o equipo especial que (FILL "él/ella" IF RTYPE=01,03; "UD." IF
RTYPE=02) necesita en un carro?

> *Code all that apply*

CAN'T AFFORD THE SPECIAL FEATURES 01

NOT ALLOWED TO MAKE CHANGES 02

DON'T KNOW HOW TO MAKE CHANGES/

WHO TO CONTACT/WHERE TO GO 03

NEVER GOT AROUND TO IT 04

![](media/image12.wmf) NOT MY DECISION/NOT MY CAR 05

OTHER (SPECIFY) 06

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DON'T KNOW d

REFUSED r

CP, YP, YA, YX

L32. CHECK AGE: Is NAME'S age...

\<17 01 *Go to Part M*

17+ 02 *Continue*

YP, YA, YX

NHIS-D Adult Followback

L33. During the past 12 months, (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE
YOU" IF RTYPE=02) used local public transportation, such as a regular
bus line, rapid transit, subway, or street car?

PROBE: Do not include school buses.

Durante los últimos 12 meses, ¿ha usado (FILL "NAME" IF RTYPE=01,03;
"UD." IF RTYPE=02) transporte público local o municipal, tal como una
línea regular de buses, transporte rápido (rapid transit), el
subterráneo (subway), o un tranvía (street car)?

PROBE: No incluya autobuses de escuela.

YES 01

NO 00

NO PUBLIC SYSTEM AVAILABLE 03 *Go to L38*

DON'T KNOW d

REFUSED r

YP, YA, YX

NHIS-D Adult Followback

L34. Does an impairment or health problem limit or prevent (FILL
"NAME'S" IF RTYPE=01, 03; "YOUR" IF RTYPE=02) use of public
transportation services?

> ¿Algún impedimento o problema de salud (le/la) limita o impide a (FILL
> "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) en el uso de servicios de
> transporte público?

YES 01

NO 00

DON'T KNOW d *Go to L38*

REFUSED r *Go to L38*

YP, YA, YX

L35. CHECK: Is L33=00, DK, RF, that is, (NAME) has not used public
transportation in the past 12 months?

YES 01 *Go to L38*

NO 00 *Continue*

YP, YA, YX

NHIS-D Adult Followback

L36. During the past 12 months, how often did (FILL "NAME" IF RTYPE=01,
03; "YOU" IF RTYPE=02) use the local public transportation services?
Would you say..

Durante los últimos 12 meses, ¿con qué frecuencia usaba (FILL "NAME" IF
RTYPE=01,03; "UD." IF RTYPE=02) los servicios locales de transporte
público?

¿Diría que . . .

Everyday or almost everyday 01

Occasionally, or 02

Seldom 03

Todos los días o casi todos los días, 01

De vez en cuando, o 02

Casi nunca? 03

DON'T KNOW d

REFUSED r

YP, YA, YX

NHIS-D Adult Followback

L37. In general, how difficult is it for (FILL "NAME" IF RTYPE=01, 03;
"YOU" IF RTYPE=02) to get to and use public transportation? Would you
say it is...

Por lo general, ¿cuán difícil es para (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02) llegar a, y usar, transporte público? ¿Diría que . . .

Very difficult 01

Somewhat difficult 02

A little difficult 03

Not at all difficult 04

Es muy difícil 01

Es algo difícil 02

Es un poco difícil 03

No hay ninguna dificultad 0

DON'T KNOW d

REFUSED r

YP, YA, YX

NHIS-D Adult Followback

L38. Some communities have special bus, cab or van services for people
who have difficulty using the regular public transportation service.
When using this special service, people can call ahead and ask to be
picked up. Is such a service available in (FILL "YOUR" IF RTYPE=01, 02;
"NAME'S" IF RTYPE=03) area?

Algunas comunidades tienen servicios de buses, taxis o minibuses (vans)
especiales, para personas que tienen dificultades en usar servicios
regulares de transporte público. Cuando usan este servicio especial, las
personas pueden llamar de antemano, y pedir que las recojan. ¿Hay tal
servicio disponible en (FILL "SU AREA" IF RYTPE=01,02 "él área de
(NAME)" IF RTYPE=03)?

YES 01

NO 00 *Go to Part M*

DON'T KNOW d *Go to Part M*

REFUSED r *Go to Part M*

YP, YA, YX

NHIS-D Adult Followback

L39. (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU" IF RTYPE=02) used this
special service in the past 12 months?

> ¿Ha usado (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) este
> servicio especial en los últimos 12 meses?

YES 01

NO 00 *Go to L44*

DON'T KNOW d *Go to L44*

REFUSED r *Go to L44*

YP, YA, YX

NHIS-D Adult Followback

L40. About how many times (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU"
IF RTYPE=02) used this service in the past 12 months?

¿Más o menos cuántas veces ha usado (FILL "NAME" IF RTYPE=01,03; "UD."
IF RTYPE=02) este servicio en los últimos 12 meses?

\|\_\_\_\|\_\_\_\|\_\_\_\| TIMES USED (0-999)

DON'T KNOW d

REFUSED r

YP, YA, YX

Created

L41. How dependable is this service? Would you say..

¿Cuánto se puede confiar en este servicio? ¿Diría que . . .

> *Read list, code only one answer*

Very dependable 01

Somewhat dependable 02

Not very dependable 03

Not dependable at all 04

Se puede confiar mucho; 01

Se puede confiar algo; 02

No se puede confiar mucho; o 03

En absolutono se puede confiar

en el servicio 04

DON'T KNOW d

REFUSED r

YP, YA, YX

Created

L42. Were there times in the past 12 months, when (FILL "NAME" IF
RTYPE=01, 03; "YOU" IF RTYPE=02) would have liked to use this service
but did not?

¿Había ocasiones en los últimos 12 meses, cuando (FILL "NAME" IF
RTYPE=01,03; "UD." IF RTYPE=02) quisiera haber usado este servicio, pero
no lo usó?

YES 01 *Continue*

NO 00 *Go to Part M*

DON'T KNOW d *Go to Part M*

REFUSED r *Go to Part M*

YP, YA, YX

NHIS-D Adult Followback (modified)

L43. Why didn't (FILL "NAME" IF RTYPE=01, 03; "YOU" IF RTYPE=02) use
this service the last time this happened?

> ¿Por qué no usó (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) este
> servicio, la última vez que ocurrió esto?
>
> *Do not read, code all that apply*
>
> DON'T NEED/WANT SERVICE 01
>
> DON'T KNOW HOW TO USE 02
>
> NEED HELP FROM ANOTHER PERSON 03
>
> CAN'T USE PHONE/DON'T HAVE PHONE 04
>
> CAN'T READ 05
>
> ILLNESS 06
>
> SERVICE UNRELIABLE/NOT DEPENDABLE 07
>
> HOURS INADEQUATE 08
>
> CAN'T GET RESERVATION FOR
>
> SERVICE 09
>
> ![](media/image13.wmf) COST 10
>
> OTHER (SPECIFY) 11
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON'T KNOW d
>
> REFUSED r

YP, YA, YX

NHIS-D Adult Followback (modified)

L44. (FILL "HAS NAME" IF RTYPE=01, 03; "HAVE YOU" IF RTYPE=02)
**needed** a special service like this in the past 12 months?

¿Ha necesitado (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02) un
servicio especial como este, en los últimos 12 meses?

YES 01 *Continue*

NO 00 *Go to Part M*

DON'T KNOW d *Go to Part M*

REFUSED r *Go to Part M*

YP, YA, YX

NHIS-D Adult Followback (modified)

L45. Why (FILL "HASN'T NAME" IF RTYPE=01, 03; "HAVEN'T YOU" IF RTYPE=02)
used this service in the past 12 months?

¿Por qué no ha usado (FILL "NAME" IF RTYPE=01,03; "UD." IF RTYPE=02)
este servicio en los últimos 12 meses?

> *Do not read, code all that apply*
>
> DON'T NEED/WANT SERVICE 01
>
> DON'T KNOW HOW TO USE 02
>
> NEED HELP FROM ANOTHER PERSON 03
>
> CAN'T USE PHONE/DON'T HAVE PHONE 04
>
> CAN'T READ 05
>
> ILLNESS 06
>
> SERVICE UNRELIABLE/NOT DEPENDABLE 07
>
> HOURS INADEQUATE 08
>
> CAN'T GET RESERVATION FOR
>
> SERVICE 09
>
> ![](media/image14.wmf) COST 10
>
> OTHER (SPECIFY) 11
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> DON'T KNOW d
>
> REFUSED r