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? Please report babies as age 0 when the child is less than 1 year old.

Print numbers in boxes.

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

2. How is this person related to Person 1?

[] Husband or wife
[] Biological son or daughter
[] Adopted son or daughter
[] Stepson or stepdaughter
[] Brother or sister
[] Father or mother
[] Grandchild
[] Parent-in-law
[] Son-in-law or daughter-in-law
[] Other relative
[] Roomer or boarder
[] Housemate or roommate
[] Unmarried partner
[] Foster child
[] Other nonrelative

4. What is Person X's age and what is Person X's date of birth? Please report babies as age 0 when the child is less than 1 year old.

Print numbers in boxes.

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

Age (in years)_ _ _

Questionnaire instructions view entire document:  text  image
Answer person questions 1 through 6 for the first five people listed on pages 2,3, and 4 of the questionnaire.

2. If the person is related to Person 1 by birth, marriage, or adoption, but is not the Husband or wife, Biological son or daughter, Adopted son or daughter, Stepson or stepdaughter, Brother or sister, Father or mother, Grandchild, Parent-in-law, Son-in-law or daughter-in-law, of Person 1, mark the "Other relative" box. Therefore, a niece or nephew of Person 1 would be categorized as "Other relative."
If a person is not related to Person 1, mark the applicable box. A "Roomer or boarder" is someone who occupies room(s) and makes cash or non-cash payment(s). A "Housemate or roommate" is someone sharing the house/apartment (but who is not romantically involved) with Person 1. An "Unmarried partner," also known as a domestic partner, is a person who shares a close personal relationship with Person 1. A "Foster child" is someone under the age of 21 who is involved in the formal foster care system. For all other people who are not related to person 1, mark the "Other nonrelative" box.

4. For each person, print this person's age and month, day, and year of birth. Print the age at the last birthday. Do not round the age up if this person is close to having a birthday. If the exact age is not known, provide an estimate. Print "0" for babies less than 1 year old.