Questionnaire Text

Questionnaire form view entire document:  text  image

A3. Date of birth

In what month and year were you born?
Fill in month and year of birth in the Western or Islamic calendars or other ____.

Month:

Year:
Western_ _
Islam/Java ____
Other____

Questionnaire instructions view entire document:  text  image

Column (4), (5), (6) and (7) Date of birth
Ask the date of birth for every person listed on the form in column (2) and record the answers. Month and year of birth can be written according to the Christian calendar or the Islamic/Javanese calendar depending on the respondent's answer. If the Christian calendar is used write two digits for the number of the month and two digits for the last two digits of the year. For example:
January 01, 1964: write "64"
February 02, 1954: write "54"
November 11, 1902: write "02"
December 12, etc.


Method of filling in the form
- If the answer is the month and year in the Christian calendar, then fill in the month in column (4) and the year in column (6).

- If the answer is the month in the Islamic calendar and the year in the Christian calendar, write the month in column (5) and the year in column (6) and so on.

- If the birth month is not known and the answer is only the birth year, then write the birth year only in column (6) or (7).

- If both the month and year of birth are unknown, then directly ask the age and put that number in column (8).