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This questionnaire contains six sections (B through G). Sections B, F, and G ask about the persons living in your household. The remaining sections (C, D, and E) ask specifically about one person living there.
The questions appear in bold type. Definitions, clarifications, and special instructions (such as instructions to skip over questions) appear in italic type.
Please answer every question unless the questionnaire instructs you to "skip" to another question. Use a dark (No. 2) pencil or pen to enter your answers.
Return your completed questionnaire in the enclosed, postage-paid envelope. If you cannot locate the envelope, please mail your completed questionnaire for processing to:
1650 Research Blvd
Rockville, MD 20850
If you have any questions about how to complete the questionnaire, please call:
Jean Wilson at 1-800-937-8281 EXT 2836
Thank you so much for your time and participation. We greatly appreciate your help!
This voluntary collection of information is authorized by Title 49 of the United States Code (section 111(c)(2)). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The time required to complete this information collection is estimated to average less than 15 minutes.