Project: Genetic structure of ethnic groups of European ancestry in North Dakota
Questionnaire
You may stop to fill this form at any time or choose not to answer a question.
DNA sample (index number)
______________________________________________
Sex M / F
Year of birth rounded to the nearest multiple of 5 __________________________________
Ethnic background ___________________________________________________________
Your place of birth ____________________________________________________________
Maternal ancestry:
Mother’s place of birth _______________________________________________________
Grandmother’s place of birth __________________________________________________
Grandfather ‘s place of birth ___________________________________________________
Paternal ancestry:
Father’s place of birth _______________________________________________________
Grandmother’s place of birth __________________________________________________
Grandfather ‘s place of birth ___________________________________________________
The places in the Old World where your ancestors came from:
Maternal ancestors __________________________________________________________
Paternal ancestors ___________________________________________________________
Surnames (the surname data will be used to select subjects that were maternally and paternally
unrelated for at least two generations):
Maternal lineage ____________________________________________________________
Paternal lineage _____________________________________________________________