Questionnaire Text

Questionnaire form view entire document:  text  image

3. What is your date of birth (or age attained?)
____ Day
____ Month
____ Year

____ Years (one year or more)
____ Months (under one year)

Questionnaire instructions view entire document:  text  image
Question 3


-- What is the date of birth (or age completed)?

The day, month, and year of birth should be requested. Then ask the number of years completed.

In the case that the person does not remember the date of birth, indicate the age [number of years] completed.

In the case of children under the age of one, the number of months completed since birth should be recorded.