Questionnaire Text

Questionnaire form view entire document:  text  image
16. Is this person currently covered by any of the following types of health insurance or health coverage plans?
Mark "Yes" or "No" for each type of coverage in items a - h.

g) Indian Health Service
[] Yes
[] No
Questionnaire instructions view entire document:  text  image
Answer person questions 7 through 17 for all persons on pages 2, 3, and 4.

Questions 7-48 are a continuation of the questions for each person. (Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)

Answer person questions 18a through 18c if this person is 5 years old or over.