Questionnaire Text

Questionnaire form view entire document: text image

Events occurred in the household in the last 12 months

Deaths: has there been any deaths in the household since _ _ _ _ [date to fill out]

(Circle the applicable number)
[] 1 Yes
[] 2 No

_ _ If yes, how many?

Questionnaire instructions view entire document: text image

Events that occurred in the household during the last 12 months

Deaths:
This applies to the death of residing members of the household. The census agent shall ask the question "Has there been any deaths in the household since January 1st, 1991?" The census agent shall treat this question carefully because it can sometimes invoke painful memories for the respondent.
If there were no deaths during the period, the census agent shall report "0" (zero) in the grid situated above the table "Deaths."
If the answer is Yes, the census agent shall ask for how many deaths occurred in the household during the last 12 months. He shall report the number in the corresponding grid.

Column (1): this is the column for the number of deaths in the household.