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All |
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Adults only |
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All |
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Person Name/ Nickname |
Age |
Relationship to Respondent |
Military status (Yes/No/DK/ REF) |
Employment status (EmpFT/EmpPT/ SelfFT/ SelfPT/ Unemployed/ Home maker/ Retired/ Disabled/Other/ DK/REF) |
Coverage (Yes/No/DK/ REF) |
Dependent on someone else’s plan (Person no. of policy holder) |
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1. (R) |
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2. |
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3. |
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4. |
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5. |
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6. |
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7. |
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8. |
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9. |
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10. |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amanda Wilmot |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |