Tentative schedule, Children's Bureau, November 6, 1912

 1. Full Name of child.
 2. No., Street, Ward.
 3. Sex of child
 4. Parents married
 5. Date of birth {Month Day Year

FATHER.
 6. Full name
 7. Residence
 8. Color
 9. Race
10. Age at last birthday
11. Birthplace
12. Occupation

MOTHER.
13. Full name
14. Residence
15. Color
16. Race
18. Birthplace
19. Occupation

20. Number of child of this mother
21. Number of children, of this mother, now living

22. Physician or midwife
23. Name
24. Address

The return of this birth is dated
25. THE NEIGHBORHOOD
a. Suburban
b. Residence
c. Semibusiness
d. Business
e. Factory
f. Exceptional
g. Good
h. Average
i. Poor
j. Slum
k. Street or alley--
I. Paved
II. Macadamized
III Unpaved
IV Sidewalk: Yes No
V. Repair--
  1. Good
  2. Fair
  3. Bad
VI. Cleanliness--
  1. Clean
  2. Dirty
  3. Filthy

26. THE HOUSE:
a. Private
b. Rooming
c. Apartment
d. Tenement
e. Detached
f. Semidetached
g. In row
h. Rear property
i. In alley or court
j. On street

27. THE HOME:
a. Venilation--
  I. Good
 II. Fair
 III. Bad
b. Cleanliness--
  I. Clean
  II. Dirty
  III. Filthy
c. Light--
  I. Light
  II. Gloomy
  III. Dark
d. Plumbing--
e. On what floor?
f. Is there elevator for use?
g. Number rooms
h. Sleeping rooms
i. Not sleeping rooms
j. Monthly rent of home $
k. Does rent include heat or other such consideration?
l. Convenience to water supply?
m. Yard?

28. BABY'S ROOM:
a. For what other purposes used?
b. Other persons sleeting in same room?
c. Does baby sleep along in separate bed?
d. Venilation--
  I. Good
  II. Fair
  III. Bad
e. Cleanliness--
  I. Clean
  II. Dirty
  III. Filthy
f. Light--
  I. Light
  II. Gloomy
  III. Dark [page 3]

COMPOSITION OF THE HOUSEHOLD:
Mother of this child
Father of this child lving, at home
Children
Relatives
Servants
Roomers
Boarders rooming in family
Total rooming in family
Table boarders not rooming with family
Aggregate

MOTHER:
Present age years.
Age at first marriage years.

FATHER:
Present age years.
Age at first marriage years.

MOTHER'S PRINCIPAL GAINFUL OCCUPATION:

Age. Occupation. Industry. Period employed. [page 4]

	Occupation.	Industry.	Place of employment.
Immediately prior to and at time of this pregnancy
During pregnancy
Since baby's birth

CONDITIONS OF GAINFUL WORK:

	DURING PREGNANCY.	SINCE BIRTH OF BABY.
		During first three months.	After first three months.
Number of hours of labor: Week
Normal day
Short day
Night
Piecework or time work
Kind of special strain at work: Carrying, lifting, reaching, speeding, overtime, standing, cramped position, etc.
Material carried to and from work
Sit or stand at work
Number and kind of machine tended
Was there mal-adjustment of machine? (Too high, too far away, etc.)

What condition of work has, in the opinion of this mother, as any time injured her for motherhood, or injured her child during pregnancy? (Use separate sheet if necessary.)

How long before confinement did gainful employment cease?

How long after confinement was it resumed? [page 5]

Extent of mother's absence from home:

During first 3 months of baby's life
From 3d to 6th of baby's life
From 6th to 9th month of baby's life
From 9th to 12th month of baby's life

Infant, how cared for in mother's absence

If by a child under 16, state age, years.

HOME DUTIES DURING PREGNANCY	BEFORE CONFINEMENT.			AFTER BABY's BIRTH.
	Alone.	With assistance.	First three months.	After first three months.
Cooking
Housecleaning
Washing:
For family
For lodgers
For others
Ironing:
For family
For lodgers
For others
Sewing and mending:
For family
For lodgers
For others
Handwork
Machine work

[page 6]

What changes in housework were made because of pregnancy?

How long before confinement did housework cease?

How long after confinement was it resumed? In part,   In full,

INCOME: Earnings of father, per week. $  ; Year, $
Earnings of mother, per week. $  ; Year, $
Earnings of children, per week. $  ; Year, $
Receipts from boarders and roomers  Year, $
Other sources  Year, $
Total income, per year $

No. of pregnancies	Name of child of born alive.	No. months carried.	Age of mother.	DATE OF BIRTH OF INFANT.			DEATH.a			Causeb.
				Year.	Month.	Day.	Year.	Month.	Day.
1st
2d
3d
4th
5th
6th
7th
8th
9th
10th
11th
12th

^a Include stillbirths, miscarriages, and abortions. ^b If due to miscarriage, abortion, premature birth, or congenital debility, give specific facts as to cause. [page 7]

MOTHER--FEEDING BABY AND CARE OF FOOD.

METHOD OF FEEDING.

Age of child during which it was fed by this method} Months, Weeks, Days

Under

to

to

to

to

to

to

to

to

to

to

to

to

Changes

1st.

2d.

3d.

4th.

5th.

6th.

7th.

8th.

9th.

10th.

11th.

12th.

Breast fed:

By mother

By wet nurse

Bottle fed:

Cow's milk--

Straight

Diluted

Modified

(a) By mother

(b) By agency

Raw

Sterilized

Pasteurized

Condensed milk

Proprietary

Solids, etc.

NOTE. -- Reasons for each change should be given by number of change.

[page 8]
If not breast fed at birth, why not?
Reasons for selecting proprietary food?
If wholly or partly bottle fed, source of milk supply? (Dairy, grocery, city milk station, charity, etc.)
Name and address of milk dealer
Milk bought, how often per day?
Milk kept on ice in warm weather?
Can mother read and write?
Speak English?
Years in United States
Intelligence of mother
Weight of baby at birth llbs.
Weight at one year of age lbs.
Health of baby at birth
Most frequent illnesses
Treatment: Home or professional (Doctor, visiting nurse, hospital, dispensary, or other.)
Drugs, stimulants, soothing [syrups]
Upon whose recommendation
Age at which first given

Circumstances affecting the family health, life, and comfort, e. g. lack of employment; sickness, serious or costly; bad habits or some member of family:

Date

Cause

Contributory cause

Attending physician: Name and address (If no physician, give particulars)

For infants in institution: Name of institution
Former or usual residence
How long at institution?
Where was disease contracted if not at institution?