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ID: __ --______________ __
APPENDIXB'
Family Background Information
1. Marital status/natural parents: 1 married
2 divorced
3 separated
4 one deceased
5 unmarried
2. Living arrangement: 1 both natural parents
2 father only
3 mother only
4 father/stepmother
5 mother/stepfather
6 other: (specify)_~ ________________________ _
3. Parents' income: 1 less than $1000
2 $1000 - 2999
3 3000 4999
4 5000 - 6999
5 7000 - 8999
6 9000 - 11999
7 12000 - 24999
8 25000 - 49999
9 50000 or more
4. Income from other sources: 1 none
2 ADC
3 social security
4 disability
5 pension
6 alimony
7 child support
8 other: (specify)
5.t
6.
Occupation of
. Occupation of
father:
mother:
~
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7.
8,
Education of
Education of
father:
mother:
9.
Criminal history of father:
ever institutionalized: 1 no
2 yes
where: 1 city/county jail
2 State Reformatory
3 State Penitentiary
4 Oakdale
5 Training School
6 other: (specify)_____________________________