ATTACHET (1-3) Time ID: Appo Intment Date: MALE FEMALE Tel.#:L Home Nane Work/ Address Al ternate Zip: State: city: Date: Interviewe D you smoke cigarettes?" CONT I NUE Yes _ In HOUSEHOLD SMOKES Ask IF ANYONE ELSE in our survey are Including people of all ages "To be sure me which of the following best described your age please tel1 Are you . Under 18. 18-24 _ 25-34 35-44 45-54 55-64 . over_ "On the average, how many cigarettes do you smoke per day? (Must SMOKE At LEAST 20 CI GARETTES (WRITE In# PER Day To CONTINUE) 8 3 26 -
ATTACHET Appo Intment Date: (1-3) Time ID: MALE FEMALE Tel.#:L Home Nane Work/ Al ternate Address Zip: State: city: Date: Interviewe D you smoke cigarettes?" Yes _ CONT I NUE Ask IF ANYONE ELSE In HOUSEHOLD SMOKES "To be sure are Including people of all ages in our survey please tel1 me which of the following best described your age Are you . Under 18. 18-24 _ 25-34 35-44 45-54 55-64 . over_ "On the average, how many cigarettes do you smoke per day? (WRITE In# (Must SMOKE At LEAST 20 CI GARETTES PER Day To CONTINUE) 8 3 26 -