(D. L.—288.)
|
.................................................................................................... Special Agent Expert |
| l. Enumeration district .................... |
2. Ward. ................... |
3. Number of dwelling- house in order of visitation. ....................... |
4. Number of family in order of visitation. .......................... |
5. Number of persons in this family ...................... |
6. House number and street.
|
| INQUIRIES. | Persons in the Family | ||||
| 1 | 2 | 3 | 4 | 5 | |
| 7. Christian name and middle initial? | |||||
| 8. Surname? | |||||
| 9. Relationship to head of family? | |||||
| 10. Sex? | |||||
| 11. Age at nearest birthday? | |||||
| 12. Conjugal condition? | |||||
| 13. Mother of how many children? | |||||
| 14. Number of them living? | |||||
| 15. Race? | |||||
| 16. Place of birth? | |||||
| 17. Place of birth of father? | |||||
| 18. Place of birth of mother? | |||||
| 19. Years in the United States? | |||||
| 20. Fully naturalized? | |||||
| 21. Naturalization papers taken out? | |||||
| 22. Months in school during the year? | |||||
| 23. Public, parochial, or what school? | |||||
| 24. Able to read native language? | |||||
| 25. Able to write native language? | |||||
| 26. Able to read English? | |||||
| 27. Able to write English? | |||||
| 28. Able to speak English? | |||||
| 29. Sick with acute or chronic disease? | |||||
| 30. Number of days sick? | |||||
| 31. Wanting or defective in mind, sight, hearing, speech; maimed or deformed? | |||||
| 32. Profession, trade, or occupation? | |||||
| 33. Place of work at above profession, trade, or occupation? | |||||
| 34. Average weekly earnings while employed at above profession, trade, or occupation? | |||||
| 35. Daily hours of work from Monday to Friday? | |||||
| 36. Daily hours of work Saturday? | |||||
| 37. Daily hours of work Sunday? | |||||
| 38. Weeks unemployed at above profession, trade, or occupation during the year? | |||||
| 39. Weeks employed at any other profession, trade, or occupation during the year? | |||||
| 40. Name of such other profession, trade, or occupation? | |||||
| 41. Place of work at such other profession trade, or occupation? | |||||
| 42. Average weekly earnings while employed at such other profession, trade, or occupation? | |||||
| 43. How subsisted when unemployed? | |||||