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Name
   
 
 
 
Gender
 
Male
 
Female

 
 
 
Age
 
25 or under
 
26- 40
 
41- 55
 
51 or older

 
 
 
Place of birth
   
 
 
 
Ethnic affiliation
   
 
 
 
Religion
   
 
 
 
Duration of stay in the company
   
 
 
 
Marital Status
 
Single
 
Married
 
Widowed
 
Separated

 
 
 
No. of children (if married)
 
1- 5
 
6-10
 
more than 10

 
 
 
Including yourself, how many people live within your household?
 
1- 5
 
6- 10
 
more than 10