146 



MASS. EXPERIMENT STATION BULLETIN 241 



Serial No. 



HOME RECORD— 5— 



V. Family Data 



A. Parents 



1. Occupation 



2. Birthplace 



3. Nationality 



Father 



B. Household 

 Mother Age Male Female 



0-1 



1-6 



6-16 



4. Approx. age 



5. Education 



16+ 



C. Cdntrilniting Factors in Poor Nutrition: 



1. Low income _ — 4. Poor discipline 



2. Indifference _ 5. Other conditions 



3. Ignorance - — - - 



D. EcOffwmic Aspects: 



1 . Residence : owned. rented _ 



2. Type residence : farm -...village other 



3. Apparent income: high medium „ low very poor. 



4. Own cow buy milk 



