Questionnaire Text

Questionnaire form view entire document: text image

6. Month and year of birth

Month

[] January to May
[] June to December

Year of birth

Decade
Fill one circle only
[] 186_
[] 187_
[] 188_
[] 189_
[] 190_
[] 191_
[] 192_
[] 193_
[] 194_
[] 195_
[] 196_
[] 197_

Actual year

Fill one circle only
[] 0
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9

Questionnaire instructions view entire document: text image

6. Print the month and year of your birth in the first section. Fill the appropriate circles in the second, third and fourth sections, one circle only should be filled for each of these sections. If the precise date of birth is not known, give the best estimate possible. Study the examples on the page on the left.