Questionnaire Text

Questionnaire form view entire document:  text  image
Person 1
(Person 1 is the person living or staying here in whose name this house or apartment is owned, bought, or being rented. If there is no such person, start with the name of any adult living or staying here.)

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 _ _ _ _

[Repeat for persons X = 2 - 5.]

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 _ _ _ _

[Repeat for Persons Y = 6 - 12.]

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.

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.