Questionnaire Text

Questionnaire form view entire document: text image

29. On what date was [the respondent] born?

____ Day
____ Month
____ Year

Questionnaire instructions view entire document: text image

Question 29: When was (NAME) born?

Record in the boxes the day, month and year of the person's birth. For example, if that person was born in 19 of February of 1975. [See the example in the picture next to it].