Name of Form

Numbers of form

Dimensions of form

Number of copies

Number of sheets

one side two sides

Number of lines

Number of check boxes

Ink color



Brand or printer

Union bug

Is the form pretty?

Agency issuing form

Size of agency
(number of employees)

Purpose of form

How was form obtained?

Where was form obtained?

When was form obtained?


refused by agency

waived by me

Are there requirements to

Number of spaces left blank or
marked 0, none, n.a., etc.

Number of redundancies
(same information required on different lines)

Time required to fill out form

Hours Minutes Seconds

Must be

Which databases does the form information go to?

Form filled out by

Was the form fun to fill out?