Questionnaire Text

Questionnaire form view entire document: text image

3a. Month of birth

[] January
[] February
[] March
[] April
[] May
[] June
[] July
[] August
[] September
[] October
[] November
[] December

3b. Year of birth (First three digits)

[] 186
[] 187
[] 188
[] 189
[] 190
[] 191
[] 192
[] 193
[] 194
[] 195
[] 196
[] 197

3c. Year of birth (last digit)

[] 0
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9

Questionnaire instructions view entire document: text image

Question 3 b and c [Birth year]
For the birth year, always check two boxes, for example:

Birth year 1893

3b = 189
3c = 3

Birth year 1946

3b = 194
3c = 6