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Survey Text

1996
1995
1994
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1996
Survey form view entire document:  text  image
SAMPLE CHILD LIST

ITEM I1
List any nondeleted persons under 6 years old in this family by age, oldest to youngest
Line No. 1

Person No.
____
Age
____
Sex
1[] M
2[] F
Last name
_____
First name
_____
SC
1[]
19-35 months
2[]
List No.
1

Refer to sample child section label and circle as applicable. Then, mark (X) the "SC" box in the column above for the selected sample child under 6.

ITEM I2A
Are there any non-selected 2 year olds in the above list?

[] Yes (Mark (X) box in "19-35 months" column for each, then I2b)
[] No (I2B)
ITEM I2B
Are there any non-selected 1 year olds in the above list?

[] Yes (Refer to Eligibility Chart for each 1 year old)
[] No (Section I)

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1995
Survey form view entire document:  text  image
Sample Child List

[option for 9 lines in the original document not presented here]
ITEM I1
List any nondeleted persons under 6 years old in this family by age, oldest to youngest
1. Line No.

Person No.
____

Age
____

Sex
1[] M
2[] F

Last name
_____

First name
_____

SC
1[]

19-35 months
2[]

List No.
1

Refer to sample child section label and circle as applicable. Then, mark (X) the "SC" box in the column above for the selected sample child under 6.

ITEM I2A
Are there any non-selected 2 year olds in the above list?

[] Yes (Mark (X) box in "19-35 months" column for each, then I2b)
[] No (I2B)
ITEM I2B
Are there any non-selected 1 year olds in the above list?

[] Yes (Refer to Eligibility Chart for each 1 year old)
[] No (Section I)

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1994
Survey form view entire document:  text  image
SAMPLE CHILD LIST

ITEM I1
Are there any nondeleted persons under 6 years old in this family?

[] Yes (List by age, oldest to youngest)
[] No (Section II, page 12)

[option for 9 lines in the original document not presented here]
1. Line no.

Person no ____
Age ____
Sex
1[] M
2[] F


Last name ____
First name ____
SC
1[]
19-35 months
2[]
List no
1[]

Refer to sample child section label and circle as applicable. THEN, mark (X) the "SC" box in the column above for the selected sample child under 6.

ITEM I2A
Are there any non-selected 2 year olds in the above list?

[] Yes (Mark (X) box in "19-35" months column for EACH, then 12B)
[] No (12B)
ITEM I2B
Are there any non-selected 1 year olds in the above list?

[] Yes (Refer to Eligibility Chart below for EACH 1 year old)
[] No (Section 1)