Current Information Occupational History Past Medical History Complete 1. Name 2. Last 4 digits of Social Security # 3. Clock Number 4. Present Occupation 5. Plant 6. Address 6. Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 7. ZIP/Postal Code 8. Phone Phone 9. Interviewer 10. Date 11. Date of Birth 12. Place of Birth 13. Sex Male Female 14. Marital Status - Select -SingleSeparated/DivorcedMarriedWidowed 15. Race - Select -WhiteHispanicBlackIndianAsianOther 16. What is the highest grade completed in school? Leave this field blank