Republic of Poland
Central Statistical Office
May 20th
____ 1 Voivodship
____ 2 Powiat
____ 3 Community (gmina)
____ 4 Town
5. Precise address of an enumerated dwelling (or other living quarter)
____ Street, number of building, and number of dwelling
____ 6. Serial number of building in enumeration district
____ 7. Number of persons enumerated in the dwelling (or in other living quarters)
8. Type of enumerated housing unit:
[] 2 Occupied other living quarter (fill in type of quarter or object) ____
____ Year of birth
____ Relationship to the head of the household
____ Number of private household
0/IV. Information on private households
1. What is the main and additional source of maintenance of household?
b) A source of taking the second position in you incomes
2. What is the tenure status of household?
[] 2 Membership of a housing co-operative (own and rented dwellings)
[] 3 Main tenant
[] 4 Sun-tenant
[] 5 Relationship (with the owner or the main tenant) or for perpetuity
[] 6 Other (i.e. work for the owner of the dwelling, help in the household, live in the building of religious institution etc.) - Specify ____
I. Population, private households, families
1 (a) Surname (family name) ____
1 (b) Name (given name) ____
_ _ Month
_ _ _ _ Year
[] 2 Female
4. Do you live here permanently and were you present or absent on May 20th at midnight or do you stay here temporarily?
[] 1 Live permanently - present - question 7
[] 2 Live permanently - absent
[] 5 Stay temporarily - arrived from abroad
5. What is the real duration of your absence or staying?
[] 1 Up to 2 months
[] 2 Between 2 and 6 months
[] 3 Between 6 and 12 months
[] 4 12 months and more
6. What is the reason of your absence or staying?
[] 1 Education
[] 2 Work
[] 3 Family reasons
[] 4 Treatment, convalescence
[] 5 Living conditions
[] 6 Living in health care institution (for child or adult)
[] 7 Other (military)
[] 8 Refugee (for foreigners)
[] 9 Other reasons (specify) ____
7. What is your relationship to the head of private household?
[] 2 Spouse
[] 3 Cohabitant (common-law partner)
[] 4 Son/ daughter
[] 5 Father/ mother
[] 6 Father-in-law/ mother-in-law
[] 7 Son-in-law/ daughter-in-law
[] 8 Brother/ sister
[] 9 Grandfather / grandmother
[] 10 Grandson/ granddaughter
[] 11 Other relative (specify: e.g. sister-in-law, uncle, niece, etc.) ____
[] 12 Non-relative person (if he/she is a common-law partner of a member of the household please fill in:
In order to separate the families from household fill in the number of parents to all persons, being children of the member of this household - fill in: Child of person No ()
No of private household ____
8. What is your legal marital status? (Persons age 15 and up)
[] 1 Single (never married), go to question 10
[] 2 Legally married (and living together), go to question 9
[] 3 Legally married (living separately), go to question 9
[] 4 Widower - widow, go to question 10
[] 5 Divorced, go to question 10
[] 6 Legally separated (de jure status), go to question 9
9. When a current marriage was contracted? (civil or religious)
_ _ _ _ Year
Education
(Questions 10 and 11 concern only persons age 13 and up)
10. What is your education level?
Higher Education:
[] 1 At least doctorate
[] 2 Master's degree, degree in medicine or equivalent
[] 3 Non-university certificate or diploma (technical institute, licentiate or bachelor or economist)
Post-Secondary:
[] 4 Post-secondary with secondary school certificate
[] 5 Post-secondary without secondary school certificate
Secondary
[] 6 Vocational and technical with certificate
[] 7 Vocational without certificate
[] 8 General with certificate
[] 9 General without certificate
[] 10 Basic vocational
Primary
[] 11 Primary completed
Others
[] 12 Primary not completed and no school education
[] 2 Yes, at evening school or weekend school and extramural system
[] 3 No
12. Are you limited completely or seriously in basic activities of daily life (up to your age), because of disability or chronic disease?
[] 2 Yes, seriously
[] 3 No
13. Do you have a valid certificate of disability?
[] 2 No, go to question 15
14. What is the category of legal confirmation of disability?
[] 2 II medium group (status) of disability
[] 3 III lowest group (status) of disability
15. What is the country of your birth?
[] 1 Poland
[] 2 Other country (specify)
[] 1 Polish (only)
[] 2 Both - Polish and other (specify) ________
[] 3 Only others (specify)
________ Name of country
17. Since when have you lived/stayed in this locality? (urban, rural community - gmina)
[] 1 Since birth day, go to question 19
[] 2 Since 1988 or longer, go to question 19
[] 3 Since 1989 or shorter, go to question 18
_ _ _ _ Year
18. Please give the name of the previous place of residence and complete the migration questionnaire M
[] 1 Other locality in Poland
b) Community (gmina) ____
c) Type of locality
[] 2 Rural areas
II. Economic activity of population
(Questions 19 to 29 concern persons age 15 and older)
19. Did you perform any work providing earnings or income or did you help pay in a family business?
[] 1 Yes, go to question 20
[] 2 You temporarily didn't work due to illness, vacation, lay-off, strike etc., but you did have a job (did not concern contributing family members) in reference week (from May 13th to May 19th), go to question 20
[] 3 No, go to question 25
[] 4 Lack of response (concerns persons staying abroad), go to question 28
20. Were you employed during the reference week as (concerns the week from May 13th to 19th):
[] 2 Part-time paid-employee
[] 3 Employer
[] 4 Own-account worker (without employees)
[] 5 Agent (in all kind of agencies)
[] 6 Members of agricultural production co-operative
[] 7 Contributing family worker
[] 8 Clergyman/woman
22. What is the main kind of economic activity of the company (institution) in which you have main job?
23. Do you perform any additional job?
[] 1 Yes, go to question 24
[] 2 No, go to question 28
24. What is the main kind of economic activity of the company (institution) in which you have additional job?
Go to question 28.
(Concerns only persons who did not perform any work providing earnings or income, and did not help pay in a family business.)
25. Are you looking for a job actively?
[] 1 Yes, go to question 26
[] 2 No, you have found a job and have been waiting to start it, go to question 27
[] 3 No, go to question 28
26. Would you be able to start working in the week from May 13th to May 19th or next providing that found a job?
[] 2 No
27. How long have you been actively looking for a job?
Holders and members of private households with an agricultural farm (plot) holder
28. Are you a holder of an agricultural farm (plot) or are you a member of a household with an agricultural farm (plot) holder?
[] 1 Yes; you are a holder of the agricultural farm/plot, go to question 29
[] 3 No, go to question 30
29. Please give the number of months worked in your agricultural farm (plot) within the last 12 months?
30. What is your main source of maintenance?
Incomes from paid-employment
[] 2 In private non-agriculture sector (including producer's co-operative)
[] 3 In public agriculture sector (state and communal establishment)
[] 4 In private agriculture sector (including producers' co-operative)
[] 6 In own private farm (or plot of land)
[] 7 In agriculture outside own private farm (or plot of land)
[] 9 Retirement pay of farmers
[] 10 Pension resulting from an inability to work
[] 11 Social pension
[] 12 Family pension
[] 13 Unemployment benefit
[] 14 Welfare allowance
[] 15 Others (specify): ____
[] 17 Incomes from leasing
[] 19 From other household
31. What is your additional (a) source of maintenance (the second position in your incomes)? ____
Or, put the number 99 if ?no concern?
32. What kind of benefits (b) from non-earned source of income do you receive?
____
____
____
[] 1 Polish
[] 2 Non-Polish (specify):____
34. What is your language most frequently spoken at home?
[] 1 Polish only
[] 2 Both Polish and other
____ Name of non-polish language
V. Characteristics of dwelling
[] 2 Yes, but it is second place occupied temporarily or seasonal
[] 3 Is not occupied/ vacant
Fill in the symbol of non-occupied ____
2. What is the type of ownership of this dwelling?
[] 2 Is owed by co-operative dwelling
[] 3 Is tenant by co-operative
[] 4 Is owned by community (gmina)
[] 5 Is owned by state property
[] 6 Is owned by establishment company
[] 7 Is owned by social building company
[] 8 Other type of ownership (specify) ____
3.Is there a kitchen in this dwelling?
[] 7 Kitchen is a part of the dining or living room
[] 8 No kitchen or a kitchen as a separated part of living room
4. Number of rooms in this dwelling?
b) Of which rooms are used exclusively for conducting economic activity (for example: office, study room, workshop, etc.) ____
5. Useful floor space of this dwelling
a) Total (i.e. total floor space of all lodgings in the dwelling: rooms, kitchens, hall, bathroom, toilet, pantry, veranda, etc.): _____
b) Of which, floor space of dwelling used exclusively for conducting economic activities: ____
6. a) Is there piped water in this dwelling?
[] 2 Yes, only cold water
[] 3 No
6. b) Is there piped hot water in this dwelling?
[] 2 Heating in dwelling or in one family building
7. Is there a bathroom with bathtub and/ or shower?
[] 2 No
8. Is there a flush toilet in this dwelling?
[] 2 No
9. Is there gas in this dwelling?
[] 2 Yes, bottle gas
[] 3 No
10. Type of heating of the dwelling
[] 2 Collective central heating: Local source of heating in multi-dwelling building
[] 3 Individual central heating
[] 4 Stores
[] 5 Others (specify): ____
11. The type of fuel or energy used for heating the dwelling
[] 1 Constant fuel (coke, coal, patent fuel, wood)
[] 2 Gas (gaseous fuel)
[] 3 Liquid fuel (propulsive fuel, fuel oil)
[] 4 Electricity
[] 5 Two kinds of fuel (i.e. gas-oil, gas-coal, etc.)
[] 6 Others (specify): ____
VI. Characteristics of buildings
[] 3 Institutional-collective living quarters (more than half of it is occupied for hotel, dormitory, convent, etc.)
[] 4 Non-residential (more than half of it is occupied for offices, dispensary, school etc.)
[] 5 Reserved for seasonal use
2. Who is the owner of this building?
[] 2 Housing co-operative
[] 3 Community (gmina)
[] 4 State property
[] 5 Working establishment company in public sector
[] 6 Working establishment company in private sector
[] 7 Social building company
[] 8 Other (i.e. religious institutions, foundation, association etc.)
Joint ownership (with separate properties of dwellings)
[] 10 Private persons and community (gmina)
[] 11 Private persons and working establishments
[] 12 Others
3. a) Period of the building construction
[] 2 1919-1944
[] 3 1945-1970
[] 4 1971-1978
[] 5 1979-1988
[] 6 1989-2002
[] 7 Under construction
3.b) If the answer is 1989 - 2002 - please fill in the year when the building was completed: ____
4. Are there water-pipes in the building?
[] 2 Yes - local system
[] 3 No
5. Is there sewage in the building?
[] 2 Yes - local system
[] 3 No
Female fertility
(Survey concerns women at the age of 16 and over present in the sample dwelling)
(Positions 1-6 are completed by an interviewer on the base of the questionnaire A)
____ 1. Voivodship*
____ 2. Powiat*
____ 3. Community (gmina)*
____ 4. Town*
____ 5. Number of questionnaire A*
____ 6. Number of person on questionnaire A
____ 7. Number of questionnaire D in enumerated dwelling
____ 7a. Number of additional questionnaires D
Answering on questions from 8 to 14 is voluntary. Your participation in this survey is very important, mainly due to small information on determinants of a decline of woman fertility in Poland. Every woman represents ca. 50 women and for this reason a refusal of answer can cause, that survey results could not be representative for all women in Poland.
Only women living in the sample dwelling can give personally answers for questions 8-14. In many cases a sign (X) should be written into boxes besides numbers, other boxes should be filled in Arabic numbers, e.g. November-11. One box should be filled by one number.
_ _ Month
_ _ _ _ Year
[] 2 Rural area
10. Are you or have you ever been married or common-law partner?
[] 2 No, go to question 12
11. Please mention in order all legal marriages and common-law partnerships
1. Number of marriage (or common-law relationship)
[] 2
[] 3
[] 4
[] 5
[] 2 No
_ _ _ _ Year
_ _ _ _ Year
12. How many live born children have you born? ____
Live born child is an infant, that after separation from its mother breathes or shows and evidence signs of life, e.g. beating of the heart, definite movement of voluntary muscles, crying.
13. Please give the information of all live born children
1. Number of children in order of bearing
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10
3. Sex
[] 2 Female
_ _ _ _ Year
14. Are you going to give birth to a child or more children?
[] 1 Yes
[] 3 I don't know
[] 4 Refused to answer
Thank you very much for your participation in the survey!
Fill in by an interviewer
The reason of non-filling of the questionnaire D (questions 8-14)
[] 2 Woman is absent during all census period
[] 3 Woman is not interested in participation in this survey
Please complete for person being outside the current place of residence for at least 12 months in 1989-2002
(Positions 1-6 are completed by an interviewer on the base of the questionnaire A)
____ 1. Voivodship*
____ 2. Powiat*
____ 3. Community (gmina)*
____ 4. Town*
____ 5. Number of questionnaire A*
____ 6. Number of person on questionnaire A
____ 7. Number of questionnaire M in enumerated dwelling
1. Is the current place of stay your permanent residence?
[] 1 Yes, go to question 5
[] 2 No, go to question 2
2. Is your permanent residence in Poland or abroad?
[] 1 Poland
[] 2 Abroad
3. Please, give the place of your permanent residence in Poland
a) Voivodship ____
b) Powiat ____
c) Community (gmina) ____
d) Type of locality
[] 2 Rural area
4. Please, give the name of the country of your permanent residence
Name of country: ____
5. Was the previous (last) place of your residence in Poland or abroad?
[] 1 Poland, go to question 6
[] 2 Abroad, go to question 7
6. Specify your previous (last) place of residence
(If it is the same place of permanent residence as has been written in question 18 in questionnaire A - please, fill only period of staying (6d). The please go to question 8 on the questionnaire M)
b) Community (gmina) ____
c) Type of locality
[] 2 Rural areas
To: Month_ _ Year _ _ _ _
7a) What was the name of the country of your previous residence: ____
To: Month_ _ Year _ _ _ _
8. Has your whole household changed the place of residence?
[] 2 No
9. What was the reason of changing the previous (last) place of residence?
[] 12 Marriage dissolution
[] 13 Family connection
[] 14 Others
[] 22 Job loss
[] 23 A risk of job loss
[] 24 Difficult transport to work
[] 25 Others
[] 32 Too high cost of living of dwelling
[] 33 Eviction
[] 34 Others
[] 42 Better access to health care
[] 43 National environment
[] 44 Others
[] 52 Participation in training occupational programs (in non-school forms)
[] 53 Others
[] 70 Refugee (concern foreigners)
[] 80 Others (specify)
10. What was your source of maintenance at the previous place of residence?
Work in agriculture:
[] 2 Paid-employment
[] 4 Paid-employment
[] 6 Pension (resulting from an inability to work, family pension, etc.)
[] 7 Unemployment benefit
[] 8 Others
[] Maintained by other persons (fill in one symbol if 1 to 9) _
11. Is the current place of stay your destination residence?
[] 2 No
The answers should be filled in order of importance.
Please, stop here the compilation.
____ First reason
____ Second reason
____ Third reason
12. Which reasons could cause your decision of changing the place of residence?
____ First reason
____ Second reason
____ Third reason