Questionnaire Text

Questionnaire form view entire document:  text  image


23. At what location did this person work last week?

If this person worked at more than one location, print where he or she worked most last week. If one location cannot be specified, see instruction guide.

"If the person worked at several locations, but reported to the same location each day to begin work, print where he or she reported. If the person did not report to the same location each day to begin work, print the words "various locations" for 23a, and give as much information as possible in the remainder of 23 to identify the area in which he or she worked mostlast week. If the person's employer operates in more than one location (such as a grocery store chain or public school system), give the exact address of the location or branch where the person worked. If the person worked in a foreign country or Puerto Rico, Guam, etc., print the name of the country in 23e and leave the other parts of 23 blank."

a. Address (Number and street)

________________________________________

If street address is not known, enter the building name, shopping center, or other physical location description.

b. Name of city, town, village, borough, etc.

____________________________________________________________________________

c. Is this place of work inside the incorporated (legal) limits of that city, town, village, borough, etc.?

[] Yes [] No, in unincorporated area
e. State __________

f. ZIP Code _______________________

Questionnaire instructions view entire document:  text  image

23. At what location did this person work last week? If this person worked at more than one location, print where he or she worked most last week. If one location cannot be specified, see instruction guide.

"If the person worked at several locations, but reported to the same location each day to begin work, print where he or she reported. If the person did not report to the same location each day to begin work, print the words "various locations" for 23a, and give as much information as possible in the remainder of 23 to identify the area in which he or she worked most last week. If the person's employer operates in more than one location (such as a grocery store chain or public school system), give the exact address of the location or branch where the person worked. If the person worked in a foreign country or Puerto Rico, Guam, etc., print the name of the country in 23e and leave the other parts of 23 blank."