Questionnaire Text

Questionnaire form view entire document: text image

Section A:

To be completed for each person in the household in a separate column. Remember to include babies. Please include yourself.

2. What is (the person's) date of birth? (Give as much information as is known.) Or else, please give this person's age in years or give an estimate.

[] DD = Day
[] MM = Month
[] YY = Year
____ YRS = Age: For babies under one year, write "0" years, if date of birth is not known.