Questionnaire Text

Questionnaire form view entire document:  text  image
VII. A. All ages
[Questions 1-13 were asked of persons of all ages]

Name____


Serial number of household member ____

Questionnaire instructions view entire document:  text  image

Column (1): Serial numbers of household members
On the form the serial numbers have been preprinted from "01" to "15". If the number of household members exceeds the number of lines provided, add a new form S. Write the word "Continued" in the upper right-hand corner of the cover page of the first form S and write the word "Continuation" in the upper right-hand corner of the cover page of the additional form S. Copy the geographic identification information from the first form S to the second form S. Change the serial numbers of household members in column (1) block IV of the second form S starting with the number "16" and so on.