Questionnaire Text

Questionnaire form view entire document:  text  image
A. General characteristics


3. What is your date of birth?

Year ____
Month _ _
Day _ _

Questionnaire instructions view entire document:  text  image
3. What is your date of birth?
Request the year, month, and day of birth and record them in the space provided. If the month and day number is less than ten, a zero is placed in the first box. E.g. the person was born on May 9, 1964.

Year: 1964
Month:05
Day:09