Marital History Topical Module Questionnaire

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-MHINTR-

Now I would like to ask a few questions about
[fill PTEMPNAME] marital history.

PRESS "ENTER" TO CONTINUE

-MSCHK-

ASK IF NECESSARY
I'd like to verify [fill PTEMPNAME]
current marital status.

[fill FRNAME] [fill LRNAME]
Marital Status: [fill marital status previously reported]
Spouse: [fill spouse previously reported]

Is this information correct?

(1) Yes, information is correct
(2) No, marital status and name of spouse are incorrect
(3) No, marital status is incorrect
(4) No, name of spouse is incorrect

-TMMS-

What is [fill PTEMPNAME] current marital status?

(1) Married, spouse present
(2) Married, spouse absent
(3) Widowed
(4) Divorced
(5) Separated
(6) Never married
@
-TMSP-

*** DO NOT READ***
ENTER THE LINE NUMBER OF [fill FRNAME] [fill LRNAME]'s SPOUSE
ASK IF NECESSARY[n]

(N) Spouse is not listed below

-XMAR-

How many times [fill HAVHAS] [fill TEMPNAME] been married?

(1) 1
(2) 2
(3) 3
(4) 4+

-DATE0-

In what month and year did
[fill TEMPNAME] get married?

MONTH @MO
YEAR @YR

-MVAGE-

Our records show that [fill TEMPNAME] [fill WASWERE]
married at age [fill age]. Is this correct?

(1) Yes
(2) No

-RMAGE-

I'd like to verify that [fill PTEMPNAME]
marriage date was [fill month] [fill year].
Is this correct?

(1) Yes
(2) No

-RMDAT-

In what month and year did [fill TEMPNAME]
get married?
(ORIGINAL ANSWERS: [fill month] [fill year])

MONTH @MO
YEAR @YR

-RMAGE1-

I'd like to verify that [fill PTEMPNAME] marriage date was
[fill month] [fill year]. Is this correct?

(1) Yes
(2) No

-RMDAT1-

In what month and year did [fill TEMPNAME]
get married?
(ORIGINAL ANSWERS: [fill month] [fill year])

MONTH @MO
YEAR @YR

-DATE1-

In what month and year did [fill TEMPNAME]
get married for the first time?

MONTH @MO
YEAR @YR

-WIDIV1-

Did [fill PTEMPNAME] first marriage end in
widowhood or divorce?

(1) Widowhood
(2) Divorce

-WIDYR1-

In what month and year [fill WASWERE]
[fill TEMPNAME] widowed?

MONTH @MO
YEAR @YR

-DIVYR1-

In what month and year [fill WASWERE]
[fill TEMPNAME] divorced?

MONTH @MO
YEAR @YR

-STOP1-

In what month and year did [fill TEMPNAME]
actually stop living with [fill HISHER] first spouse?

MONTH @MO
YEAR @YR

-DATE2-

In what month and year did [fill TEMPNAME]
get married for the second time?

MONTH @MO
YEAR @YR

-WIDIV2-

Did [fill PTEMPNAME] second marriage end in
widowhood or divorce?

(1) Widowhood
(2) Divorce

-WIDYR2-

In what month and year [fill WASWERE]
[fill TEMPNAME] widowed?

MONTH @MO
YEAR @YR

-DIVYR2-

In what month and year [fill WASWERE]
[fill TEMPNAME] divorced?

MONTH @MO
YEAR @YR

-STOP2-

In what month and year did [fill TEMPNAME]
actually stop living with [fill HISHER] second spouse?

MONTH @MO
YEAR @YR

-DATER-

In what month and year did [fill TEMPNAME]
get married most recently?

MONTH @MO
YEAR @YR

-WIDYRR-

In what month and year [fill WASWERE]
[fill TEMPNAME] widowed?

MONTH @MO
YEAR @YR

-DIVYRR-

In what month and year [fill WASWERE]
[fill TEMPNAME] divorced?

MONTH @MO
YEAR @YR

-STOPR1-

When did [fill TEMPNAME] actually stop living with
[fill HISHER] spouse?

MONTH @MO
YEAR @YR

-STOPR2-

When did [fill TEMPNAME] actually stop living with
[fill HISHER] last spouse?

MONTH @MO
YEAR @YR

-MHIST-

***(PROBE TO CORRECT THE INCONSISTENT DATES. EACH DATE IN THE
FOLLOWING LIST SHOULD BE LATER THAN THE PREVIOUS DATE. AN "X"
INDICATES AN INCONSISTENT DATE.)***

Some of the dates I have recorded for [fill TEMPNAME]
appear to be inconsistent.
(ENTER "N" FOR NONE/NO MORE CORRECTIONS.)

FIRST MARRIAGE Month Year
1. Date of First marriage: [fill month] [fill year]
2. Date of Separation: [fill month] [fill year]
3. Date of Widowhood/Divorce: [fill month] [fill year]

SECOND MARRIAGE
4. Date of Second marriage: [fill month] [fill year]
5. Date of Separation: [fill month] [fill year]
6. Date of Widowhood/Divorce: [fill month] [fill year]

CURRENT or MOST RECENT MARRIAGE
7. Date of Most Recent marriage: [fill month] [fill year]
8. Date of Separation [fill month] [fill year]
9. Date of Widowhood/Divorce: [fill month] [fill year]
end of content rule

Page Last Modified: May 12, 2006

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