Questionnaire Text

Questionnaire form view entire document: text image

11. What is your situation?

You work
[] 1 Check the box and continue to the back of the page (questions 15 to 24) including if you are on sick leave or maternity leave, if you help a member of your family in his/her work or if you are apprenticed under contract, or a salaried intern. [skip to question 15]
You don't work (or no longer work)
[] 2 Check the box and answer questions 12 to 14

[Questions 15-21 were asked of persons who work per question 11.]

18. Where do you work?

a) Address of your workplace: (ex. 18, boulevard Pasteur) ____
If you work at home, write "at home"
If you work at an individual's home, write "individual"
If the workplace is variable, write "variable"
Is work in the city where you live? (or in the city neighborhood in the case of Paris, Lyon or Marseille)
[] 1 Yes
[] 2 No
If not, write in the city where you do work: (specify the city neighborhood)
City ____
County _ _
b) ____ Name (or corporate name) of the establishment which employs you or which you manage
c) ____ Address of this establishment if it is different than that specified in question 18a.
d) ____ Activity of this establishment
Be very specific: (ex. wholesale business of fruits and vegetables, production of mechanical equipment, etc.)