Questionnaire Text

Questionnaire form view entire document:  text  image
4. What is person 1's age and what is Person 1's date of birth?

For babies less than 1 year old, do not write the age in months. Write 0 as the age. Print numbers in boxes.

Age (in years) _ _ _
Month _ _
Day _ _
Year of birth _ _ _ _

4. What is Person X's age and what is Person X's date of birth?

For babies less than 1 year old, do not write the age in months. Write 0 as the age. Print numbers in boxes.

Age (in years) _ _ _
Month _ _
Day _ _
Year of birth _ _ _ _
Questionnaire instructions view entire document:  text  image
Person questions 1-6

Answer questions 1-6 for the first five people living or staying at this address.

  • Include everyone who is living or staying here for more than 2 months.
  • Include yourself if you are living here for more than 2 months.
  • Include anyone else staying here who does not have another place to stay, even if they are here for 2 months or less.
  • Do not include anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

P4. For each person, print this person's age and month, day, and year of birth.