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TOBACCO SMOKE EXPOSURE QUESTIONNAIRE
A. GENERAL BACKGROUND page 1 of 4
1. What is your date of birth? *(MM/DD/YYYY) / /
2. Current marital status(please select one answer):
Married/Domestic Partner Widowed
Divorced Never Married
Separated  
3. How many people, including yourself*, live in your household?
(*If you live alone, please skip to question 5.)
4. Please provide the age and relationship, to you, of the persons in your household:
Age Relationship
5.a. What is your current occupation? (If retired or umemployed, please state.)
5.b. Number of years you have been in your current occupation/retired/unemployed:
6. Have you ever been employed as an airline flight attendant? Yes No
(*If you answer NO, please go to question 8.)
a. Dates worked as a FULL-TIME flight attendant (MM/YYYY): / to /
b. Dates worked as a PART-TIME flight attendant (MM/YYYY): / to /
c. Section worked: Smoking Non-smoking Both Not separated
d. Cabin worked: First Business Coach
e. Majority of routes: Domestic (U.S.) International
 
7. Please list other former occupations and approximate dates of employment:
(List only occupations of at least 2 years duration; list in broad categories such as, "business executive", "health care worker", "bar/restaurant employee", "student")
Start with your most recent occupation and work back.
Occupation Dates (MM/YYYY)
/ to /
/ to /
/ to /
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