Interviewer Name:  _________________________________________________
 

1. Name and Address of Informant:
2. Date and Time of Interview:
3. Place of Interview:
4. Name and address of Person, if any, who put you in touch with informant:
5. Name and address of person, if any accompanying you:
6. Description of room, house, surroundings, etc.:

Interview

1. Ancestry:
2. Place and date of birth:
3. Family:
4. Places lived in , with dates:
5. Education, with dates:
6. Occupations and accomplishments, with dates:
7. Special skills and interests:
8. Community and religious activities:
9. Description of informant:
10. Other Points gained in the interview: