I (1) NAME (2) Present Address (3) Since No. ---------------------------------------------------------------------- (4) Age (5) S. M. W. (6) Health ---------------------------------------------------------------------- (7) Occupation (8) Employer (9) Hours Daily (10) Weekly Wage ---------------------------------------------------------------------- (11) Kind of House (12) Rooms in House (13) Water Supply (14) Toilet ---------------------------------------------------------------------- (15) No. in House (16) No. in Bedroom (17) No. Beds (18) No. Windows in Room ---------------------------------------------------------------------- (19) How Does He (20) Leisure Time ---------------------------------------------------------------------- Spend Money (a) Church ---------------------------------------------------------------------- Weekly? (b) Saloon ---------------------------------------------------------------------- (a) Room (c) ---------------------------------------------------------------------- (b) Board ---------------------------------------------------------------------- (c) or Family (21) Court Record ---------------------------------------------------------------------- II (a) Former Address (c) Last Employer (d) Hours Daily ---------------------------------------------------------------------- (b) Former Occupations (e) Weekly Wage ====================================================================== (f) Family (h) Weekly (age) (g) Kind of Work Wage ---------------------------------------------------------------------- W. 2 (i) Why Left Home? ---------------------------------------------------------------------- Ch. 3 (j) Who Paid Carfare Here? ---------------------------------------------------------------------- Ch. 4 (k) Will Family Come Here? ---------------------------------------------------------------------- Ch. 5 (l) When? ---------------------------------------------------------------------- Ch. 6 (m) Live Where ---------------------------------------------------------------------- Ch. 7 (n) When Will He Go Back ---------------------------------------------------------------------- Ch. 8 (o) Why? ---------------------------------------------------------------------- Ch. 9 ---------------------------------------------------------------------- Total Income