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2011 National Household Survey Canada
Statistics Canada
Statistique Canada

Message from the Chief Statistician of Canada:

The National Household Survey is an important survey for all people in Canada, including those living in northern and arctic regions, and in First Nations and other Aboriginal communities. Your input is essential so that your community and Aboriginal organizations have the information they need for planning services such as child care, schooling, family services, housing, roads and public transportation, and skills training for employment. By law, your responses will be kept confidential. Your information may be used by Statistics Canada in support of our other surveys or for analysis.

Thank you for your cooperation.

Complete the questionnaire: Please print using capital letters and mark circles with an X.

Any questions? Call us free of charge 1-877-308-277 www.nhs.statcan.gc.ca

This information is collected under the authority of the Statistics Act, R.S.C. 1985, c. S-19.
Confidential when completed.

[Page 1]

Step A
1. Print the address:

No. and street or lot and concession: ____
Apt./room/unit: ____

City, municipality, town, village, Indian reserve: ____
Province/territory: _ _
Postal code: _ _ _ _ _ _

Print the telephone number (_ _ _ ) _ _ _ - _ _ _ _

Step B
1. How many persons usually live at this address on May 10, 2011, including yourself?

Include all persons who have their main residence at this address, even if they are temporarily away. See the instructions on page 3 (joint custody, students, permanent residents, secondary residence, etc.)

_ _ Number of persons

2. Please give me the name of each person who usually lives here on May 10, 2011. Start with an adult followed, if applicable, by that person's spouse or common-law partner and their children. Continue with all other persons who usually live at this address. Give family name and given name for each person in the household.

Family name ____
Given name ____

Step C
Read list of names back to respondent, then ask:

Did you leave anyone out because you were not sure the person should be listed?
(For example, a person living at this address who has another home, a person temporarily away, etc.)

[] No
[] Yes [See the instructions on page 3. Add the additional names in Step B, if applicable.]

Step D
Copy the names in step B to question 1 on top of page 4. Keep the same order. If there are more than five persons in this household, enter the first five on this questionnaire and continue on a second questionnaire. Remember to list the 6th person in the column marked "person 3".

[Page 2]

1. Who to include in step B?

All persons who have their main residence at this address on May 10, 2011, including newborn babies, room-mates, boarders, foster children, persons who are temporarily away, and all other related and unrelated persons living here;

Canadian citizens, permanent residents (landed immigrants), persons asking for refugee status (refugee claimants), persons from another country with a work or study permit and family members living here with them;

Persons staying at this address temporarily on May 10, 2011 who have no main residence elsewhere.

2. Where to include persons with more than one residence

Children in joint custody should be included in the home of the parent where they live most of the time. Children who spend equal time with each parent should be included in the home of the parent with whom they are staying on May 10, 2011.

Students who return to live with their parents during the year should be included at their parents' address, even if they live elsewhere while attending school or working at a summer job.

Spouses or common-law partners temporarily away who stay elsewhere while working or studying should be listed at the main residence of their family, if they return periodically.

Persons in an institution who have been there for less than six months (for example, in a home for the aged, a hospital or a prison) should be listed at their usual residence.
If this address is:
[] A secondary residence (such as a cottage) for all persons who stayed here on May 10, 2011 (all these persons have their main residence elsewhere in Canada), mark this circle. [Do not answer other questions.]

[] A dwelling occupied only by residents of another country visiting Canada (for example, on vacation or on a business trip), mark this circle. [Do not answer other questions.]

[] The home of a government representative of another country (for example, embassy or high commission) and family members, mark this circle. [Do not answer other questions.]

[] A dwelling that was occupied by a different household on May 10, 2011 (that is, all persons in this household lived at another address on May 10, 2011), mark this circle. [Do not answer other questions.]

End of interview.

1. Copy the name of each person in the same order as step B. Then ask the questions for each person. The questions refer to each person's situation on May 10, 2011 unless otherwise specified.

Family name: ____
Given name: ____
[] Age 15+

2. Is this person male or female?

[] Male
[] Female

3. What is this person's date of birth and age?

If exact date is not known, enter best estimate. For children under the age of 1, enter 0. If born before May 10, 1996, mark "x" in the "15+" box under the person's name.

Date of birth
Day: _ _ Month: _ _ Year: _ _ _ _
Age: _ _ _

4. Is this person…

Mark an x in one circle only. People who are married according to traditional First Nations or aboriginal customs should be considered as legally married.

[] Never legally married
[] Legally married (and not separated)
[] Divorced
[] Widowed

5. Is this person living with a common-law partner?

Common-law refers to two people who live together as a couple but who are not legally married to each other.

[] Yes
[] No

6. How is this person related to [enter name of person 1: ____]

Person 1:

[] Person 1

Person 2:

Mark "x" and specify one response.

Adopted children should be considered sons and daughters.

Children in joint custody should be included in the home of the parent where they live most of the time.

Children who spend equal time with each parent should be included in the home of the parent with whom they are staying on May 10, 2011.

For all children, please consider the relationship to Person 1 and Person 2.

If none of the choices apply, specify this person's relationship to Person 1 under "other."
Examples of "other" relationships to Person 1:
Brother-in-law or sister-in-law
Niece or nephew
Grandfather or grandmother
Room-mate's son or daughter
Lodger's husband or wife
Employee, etc.
[] Opposite-sex husband or wife of person 1
[] Opposite sex common-law partner of person 1
[] Same-sex married spouse of person 1
[] Same-sex common-law partner of person 1
[] Son-in-law or daughter-in-law of person 1
[] Grandchild of person 1
[] Father or mother of person 1
[] Father-in-law or mother-in-law of person 1
[] Brother or sister of person 1
[] Foster child
[] Room-mate, lodger or boarder
[] Other -- Specify: ____

[Page 4]

Activities of daily living

7. Does this person have any difficulty hearing, seeing, communicating, walking, climbing stairs, bending, learning or doing any similar activities?

[] Yes, sometimes
[] Yes, often
[] No

8. Does a physical condition or mental condition or health problem reduce the amount or the kind of activity this person can do:

(a) At home?
[] Yes, sometimes
[] Yes, often
[] No

(b) At work or at school?
[] Yes, sometimes
[] Yes, often
[] No
[] Not applicable

(c) In other activities, for example, transportation or leisure?
[] Yes, sometimes
[] Yes, often
[] No

Sociocultural information

9. Where was this person born?

Specify one response only, according to present boundaries.

Born in Canada:
[] Newfoundland and Labrador
[] Manitoba
[] Prince Edwards Island
[] Saskatchewan
[] Nova Scotia
[] Alberta
[] New Brunswick
[] British Columbia
[] Quebec
[] Yukon
[] Ontario
[] Northwest Territory
[] Nunavut
Outside of Canada:
[] Born outside Canada -- Specify country: ____

If this person lives on an Indian reserve, go to Question 13.

10. Of what country is this person a citizen?

Indicate more than one citizenship, if applicable.

"Canada, by naturalization" refers to the process by which an immigrant is granted citizenship of Canada, under the Citizenship Act.

[] Canada, by birth
[] Canada, by naturalization
[] Other country -- Specify: ____

[Page 6]

11. Is this person now, or has this person ever been, a landed immigrant?

A "landed immigrant" (permanent resident) is a person who has been granted the right to live in Canada permanently by immigration authorities.

[] No [Go to question 13.]
[] Yes

12. In what year did this person become a landed immigrant?

If exact year is not known, enter best estimate.

Year: _ _ _ _

13. Can this person speak English or French well enough to conduct a conversation?

[] English only
[] French only
[] Both English and French
[] Neither English nor French

14. What language(s), other than English or French, can this person speak well enough to conduct a conversation?

Examples of Aboriginal languages: Cree, Inukitut, Ojibway, Innu, Mi'kmaq, Dakota, Dene, Michif, etc.

[] None
Or
[] Specify other languages: ____

15. Languages

(a) What language does this person speak most often at home?
[] English
[] French
[] Other -- Specify: ____

b) Does this person speak any other languages on a regular basis at home?
[] No
[] Yes, English
[] Yes, French
[] Yes, Other -- Specify: ____

16. What is the language that this person first learned at home in childhood and still understands?

If this person no longer understands the first language learned, indicate the second language learned.

[] English
[] French
[] Other -- Specify: ____

[Page 8]

17. What were the ethnic or cultural origins of this person's ancestors?

This question collects information on the ancestral origins of the population and provides information about the composition of Canada's diverse population.

An ancestor is usually more distant than a grandparent.

For example, Cree, Ojibway, Mi'kmaq, Salish, Dene, Blackfoot, Inuit, Métis, Canadian, French, English, German, etc.

Specify as many origins as applicable using capital letters: ____

18. Is this person an Aboriginal person, that is, First Nations (North American Indian), Métis or Inuk (Inuit)?

Note: First Nations (North American Indian) includes Status and Non-Status Indians.

If "yes," mark "x" the circle(s) that best describe(s) this person now.

[] No, not an Aboriginal person [Continue with the next question.]
[] Yes, First Nations (North American Indian) [Go to Question 20.]
[] Yes, Metis [Go to Question 20.]
[] yes, Inuk (Inuit) [Go to Question 20.]

19. Is this person:

[This question was asked of respondents who are not Aboriginal persons, that is, First Nations (North American Indian), Métis or Inuk (Inuit), per question 18.]

Mark "x" more than one or specify, if applicable.

This information is collected in accordance with the Employment Equity Act and its Regulations and Guidelines to support programs that promote equal opportunity for everyone to share in the social, cultural, and economic life of Canada.

[] White
[] South Asian (e.g., East Indian, Pakastani, Sri Lankan, etc.)
[] Chinese
[] Black
[] Filipino
[] Latin American
[] Arab
[] Southeast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian, etc.)
[] West Asian (e.g., Iranian, Afghan, etc.)
[] Korean
[] Japanese
[] Other- Specify: ____

20. Is this person a Status Indian (Registered or Treaty Indian as defined by the Indian Act of Canada)

[] No
[] Yes, Status Indian (Registered or Treaty)

[Page 10]

21. Is this person a member of a First Nation/Indian band?

If "yes", give name of First Nation/Indian band.

For example, Musqueam Indian Band, Sturgeon Lake First Nation, Atikamekw of Manawan.

[] No
[] Yes, member of a First Nation / Indian band
Specify name of First Nation / Indian band ____

22. What is this person's religion?

Indicate a specific denomination or religion even if this person is not currently a practicing member of that group.

For example, Roman Catholic, Anglican, United Church, Pentecostal, Traditional (Aboriginal) Spirituality, Longhouse, Baptist, Lutheran, Church of Jesus Christ of Latter-day Saints, Jehovah's Witnesses, Presbyterian, Moravian, Evangelical Missionary Church, etc.

[] Specify one denomination or religion only. ____
[] No religion

Mobility

23. Where did this person live 1 year ago, that is, on May 10, 2010?

Mark "x" one circle only.

Note: For those who mark the fourth circle: Identify the community, municipality or Indian reserve rather than the name of the First Nation / Indian band.
For example:
Lac Brochet 197A, Manitoba, rather than Northlands Band;
Wabamun 133A, Alberta, rather than Paul Band;
Fort Providence, Northwest Territories, rather than Deh Gah Gotie Dene Council;
Fort Hope 64, Ontario, rather than Eabametoong First Nation;
Mingan, Québec, rather than Les Innus de Ekuanitshit.
[] Born after May 10, 2010
[] Lived at the same address as now
[] Lived at a different address in the same city, town, village, township, municipality or Indian reserve
[] Lived in a different city town, village, township, municipality or Indian reserve in Canada. Specify name of community, city, town, village, township, municipality or Indian reserve: ____
Province/territory: ____
Postal code _ _ _ _ _ _
[] Lived outside Canada. Specify country: ____

[Page 12]

[This questions were asked of all persons aged 5+]
24. Where did this person live 5 years ago, that is, on May 10, 2006?

Mark "x" one circle only.

Note: For those who mark the fourth circle: Identify the community, municipality or Indian reserve rather than the name of the First Nation / Indian band.

For example:
Lac Brochet 197A, Manitoba, rather than Northlands Band;
Wabamun 133A, Alberta, rather than Paul Band;
Fort Providence, Northwest Territories, rather than Deh Gah Gotie Dene Council;
Fort Hope 64, Ontario, rather than Eabametoong First Nation;
Mingan, Québec, rather than Les Innus de Ekuanitshit.

[] Born after May 10, 2006
[] Lived at the same address as now
[] Lived at a different address in the same city, town, village, township, municipality or Indian reserve
[] Lived in a different city town, village, township, municipality or Indian reserve in Canada.
Specify name of community, city, town, village, township, municipality or Indian reserve: ____
Province: ____
Postal code _ _ _ _ _ _
[] Lived outside Canada. Specify country: ____

Place of birth of parent

25. Where was each of this person's parents born?

(a) Father.
Mark "x" or specify country according to present boundaries.

[] Born in Canada
[] Born outside Canada. Specify country: ____

(b) Mother.
Mark "x" or specify country according to present boundaries.

[] Born in Canada
[] Born outside Canada. Specify country: ____

Questions 27 through 55 are only for persons aged 15 years and over (born before May 10, 1996).

Education

27. Has this person completed a secondary (high) school diploma or equivalent?

Examples of secondary (high) school equivalency certificates are General Educational Development (GED) and Adult Basic Education (ABE).

Secondary (high) school diploma or certificate:
[] Yes, secondary (high) school diploma
[] Yes, secondary (high) school diploma
[] No

[Page 14]

28. Has this person completed a Registered Apprenticeship or other trades certificate or diploma?

Mark "x" as many circles as applicable.
For example, hairstyling, cooking, electrician, carpentry.

Registered Apprenticeship or trades certificate or diploma:
[] Yes, Registered Apprenticeship certificate (including Certificate of Qualification, Journeyperson's designation)
[] Yes, other trades certificate or diploma
[] No

29. Has this person completed a college, CEGEP, or other non-university certificate or diploma? (Other than certificates or diplomas reported in Question 28.)

Mark "x" as many circles as applicable.
For example, nurse's aide, law enforcement, information technology, youth services, teaching assistant, forestry industry.

[] College, CEGEP or other non-university certificate or diploma
[] Yes, certificate or diploma from a program of less than 3 months
[] Yes, certificate or diploma from a program of 3 months to less than 1 year
[] Yes, certificate or diploma from a program of 1 year to 2 years
[] Yes, certificate or diploma from a program of more than 2 years
[] No

30. Has this person completed a university certificate, diploma or degree?

Mark "x" as many circles as applicable.

[] University certificate, diploma or degree
[] Yes, university certificate or diploma below bachelor level
[] Yes, bachelor's degree (including LL.B.)
[] Yes, university certificate or diploma above bachelor level
[] Yes, master's degree
[] Yes, degree in medicine, dentistry, veterinary medicine, or optometry
[] Yes, earned doctorate
[] No

[Page 16]

31. What was the major field of study of the highest certificate, diploma or degree that this person completed?

Please be specific. For example, automobile mechanics, natural resources conservation, civil engineering, heavy equipment operation, early childhood education, political science. Print in capital letters as follows:
[Diagram of how to fill in boxes with letters is omitted]

[] Major field of study of highest certificate, diploma, or degree: ____
[] No certificate, diploma, or degree (higher than high school). [Go to question 33.]

32. In what province, territory or country did this person complete his or her highest certificate, diploma or degree?

[This question was asked of persons with certificate, diploma, or degree higher than high school.]

In Canada
Specify province or territory: ____
Outside Canada
Specify country: ____

33. At any time since September 2010, has this person attended a school, college, CEGEP or university?

Mark "x" as many circles as applicable.

Please include attendance only for courses that can be used as credits towards a certificate, diploma or degree (including distance education).

At any time since September 2010:
[] Yes, attended elementary, junior high school or high school
[] Yes, attended trade school, business school, community college, technical institute, CEGEP or other non-university institution
[] Yes, attended university
[] No, did not attend school at any time since September 2010

[Page 18]

[Remember Questions 27 through 55 are only for persons age 15 and older]

Note: Many of the following questions refer to the week from Sunday, May 1 to Saturday, May 7, 2011. Call 1-877-308-2777 for more information.

Labour market activities

The next few questions were asked of persons aged 15+ about paid work.

34. During the week of Sunday, May 1 to Saturday, May 7, 2011, how many hours did this person spend working for pay or in self-employment?

Please enter the total number of hours worked for pay or in self-employment at all jobs held during the week of May 1 to May 7.

Include:
Working for wages, salary, tips or commission;
Waking, selling or trading arts and crafts;
Running a business;
Trapping, hunting and fishing (except as a leisure activity);
Fixing gear used to hunt, fish or trap;
Working as a guide.
[] Number of hours (to the nearest hour): _ _ _ [Go to question 40.]
[] None [Continue with the next question.]

[Questions 35-39 were asked of persons age 15+ who did not work for pay or in self-employment during the week of Sunday, May 1 to Saturday, May 7, 2011, per question 34.]

35. During the week of May 1 to May 7, was this person on temporary lay-off or absent from his / her job or business?

Mark "x" one circle only.

[] No
[] Yes, on temporary lay-off from a job to which this person expects to return
[] Yes, on vacation, ill, on strike or locked out, or absent for other reasons

36. During the week of May 1 to May 7, did this person have definite arrangements to start a new job within the next four weeks?

[] No
[] Yes

[Page 20]

37. Did this person look for paid work during the four weeks from April 10 to May 7, 2011?

For example, did this person contact an employment centre, check with employers, place or answer newspaper ads, etc.?

Mark "x" one circle only.

[] No [Go to Question 39.]
[] Yes, looked for full-time work
[] Yes, looked for part-time work (less than 30 hours per week)

38. Could this person have started a job during the week of Sunday, May 1 to Saturday, May 7, 2011 had one been available?

[This question was asked of persons age 15+ who looked for paid full-time or part-time work during the four weeks from April 10 to May 7, 2011, per question 37.]

Mark "x" one circle only.

[] Yes, could have started a job
[] No, already had a job
[] No, because of temporary illness or disability
[] No, because of personal or family responsibilities
[] No, going to school
[] No, other reasons

39. When did this person last work for pay or in self-employment, even for a few days?

Mark "x" one circle only.

[] In 2011 [Continue with the next question.]
[] In 2010 [Continue with the next question.]
[] Before 2010 [Go to Question 53.]
[] Never [Go to Question 53.]

Note: Questions 40 to 49 refer to this person's job or business during the week of May 1 to May 7, 2011. If this person held no job, answer for the job of longest duration since January 1, 2010. If this person held more than one job, answer for the job at which he or she worked the most hours.

[Questions 40-52 were asked of persons age 15+ who last worked for pay or in self-employment in 2011 or 2010, per question 39.]

[Page 22]

40. For whom did this person work?

For self-employed persons, enter the name of their business. If the business does not have a name, enter the person's name. Print in capital letters as follows: Name of firm, government agency, etc.

Name of firm, government agency, etc.: ____

Section, plant, department, etc. (if applicable): ____

41. What kind of business, industry or service was this? ____

Please give details. For example:
Police
Fishing, trapping
Primary school
Community health centre
Freight trucking company
Independent artist
Hair salon

42. What was this person's work or occupation? ____

Please be specific. For example:
Police officer
Trapper
Primary school teacher
Community health nurse
Truck driver
Artisan
Hairdresser
(If in the Armed Forces, give rank.)

43. In this work, what were this person's main activities? ____

Please give details. For example:
Law enforcement
Skinning animals
Teaching Grade 2
Treating patients
Driving a truck
Carving soapstone
Cutting hair

[Page 24]

44. In this job or business, was this person mainly:

Mark "x" one circle only.

[] Working for wages, salary, tips or commission [Go to Question 46.]
[] Working without pay for his/her spouse or another relative in a family farm or business [Go to Question 46.]
[] Self-employed without paid help (alone or in partnership)
[] Self-employed with paid help (alone or in partnership)

45. If self-employed, was this person's farm or business incorporated?

[This question was asked of persons who were self-employed, per question 44.]

[] No
[] Yes

46. At what address did this person usually work most of the time?

Note: For those who mark the fourth circle: Identify the community, municipality or Indian reserve rather than the name of the First Nation / Indian band.

For example:
Lac Brochet 197A, Manitoba, rather than Northlands Band;
Wabamun 133A, Alberta, rather than Paul Band;
Fort Providence, Northwest Territories, rather than Deh Gah Gotie Dene Council;
Fort Hope 64, Ontario, rather than Eabametoong First Nation;
Mingan, Québec, rather than Les Innus de Ekuanitshit.
If the address of work is different than the address of the employer, please provide the address where this person actually works (e.g., school teachers should provide the address of their school, not the address of the school board).

[] Worked at home (including farms). [Go to Question 49]
[] Worked outside Canada. [Go to Question 49]
[] No fixed workplace address. [Continue with the next question.]
[] Worked at the address specified below. Specify complete address:
Street address: ____
Community, city, town, village, township, municipality or Indian reserve: ____
Province/territory: ____
Postal code: _ _ _ _ _ _

[Page 26]

[Questions 47-48 asked of persons age 15+ who worked for pay or in self-employment and whose workplace was not at home (including farms) or outside Canada, per question 46.]

47. (a) How did this person usually get to work?

If this person used more than one method of travel to work, mark the one used for most of the travel distance.

Mark "subway or elevated rail" for:
Vancouver SkyTrain
Toronto Subway/RT
Montréal Metro
Mark "light rail, streetcar or commuter train" for:
Vancouver West Coast Express
Calgary CTrain
Edmonton LRT
Toronto streetcars
Toronto GO Train
Ottawa O-Train
Montréal commuter trains
Mark "other method" for:
ATVs and snowmobiles
Airplane
Boat
[] Car, truck or van, as a driver [Continue with question 47 (b).]
[] Car, truck or van, as a passenger [Continue with question 47 (b).]
[] Bus [Go to Question 48 (a).]
[] Subway or elevated rail [Go to Question 48 (a).]
[] Light rail, streetcar, or commuter train [Go to Question 48 (a).]
[] Passenger ferry [Go to Question 48 (a).]
[] Walked to work [Go to Question 48 (a).]
[] Bicycle [Go to Question 48 (a).]
[] Motorcycle, scooter, or moped [Go to Question 48 (a).]
[] Other method [Go to Question 48 (a).]

47. (b) How many people, including this person, usually shared the ride to work in this car, truck or van?

[This question was asked of persons who get to work by car, truck or van, either as a driver or passenger, per question 46.]

[] Drove alone
[] 2 people
[] 3 or more people

48. (a) What time did this person usually leave home to go to work?

Hour: _ _
Min: _ _
[] A.M.
[] P.M.

48. (b) How many minutes did it usually take this person to get from home to work?

Minutes: _ _ _

[Page 28]

[Questions 49 through 50 were asked of persons aged 15+ who last worked in 2010 or 2011]

49. (a) In this job, what language did this person use most often?

[] English
[] French
[] Other -- Specify: ____

49. (b) Did this person use any other languages on a regular basis in this job?

[] No
[] Yes, English
[] Yes, French
[] Yes, other -- Specify: ____

50. In how many weeks did this person work in 2010?

Please enter the total number of weeks worked for pay or in self-employment at all jobs held in 2010.

Include those weeks in which this person:
Was on vacation or sick leave with pay;
Worked full time or part time;
Worked for wages, salary, tips or commission;
Was self-employed;
Worked directly toward the operation of a family farm or business without formal pay arrangements.
[] None [Go to question 53.]
[] Number of weeks: _ _

[Questions 51-52 were asked of persons who have worked in 2010.]

51. During most of those weeks, did this person work full time or part time?

Mark "x" one circle only.
[] Full time (30 hours or more per week)
[] Part time (less than 30 hours per week)

52. In 2010, did this person pay for child care, such as day care or babysitting, so that this person could work at his or her paid job(s)?

When child care or day camps help several people work, enter the amount only once.

Answer "yes" or "no."
If "yes," also enter the total amount for 2010.

[] Yes: $: _ _, _ _ _.00
[] No

[Page 30]

Remember, these questions are only for persons aged 15 years and over.

53. In 2010, did this person pay child or spousal support payments to a former spouse or partner?

Support payments are covered by an agreement to pay a fixed amount on a regular basis. Exclude all other gifts or transfers of money. Include only support payments actually paid.

Answer: "yes" or "no."
If "yes," also enter the total amount of 2010.

[] Yes: $: _ , _ _ _, _ _ _.00
[] No

Income in 2010
[Question 55 were asked of all persons aged 15+]

54. To save time, each person can give Statistics Canada permission to use the income information already available in his or her income tax files instead of answering question 55.

This option is only available for persons who filed or intend to file a tax return for the year ending December 31, 2010.

Please note that your income tax information will be used for statistical purposes only.

Does this person give Statistics Canada permission to use the income tax information available in his / her income tax files for the year ending December 31, 2010?

[] Yes Person 1 agrees. [Go to step E on page 38.]
[] No [Continue with the next question.]

55. During the year ending December 31, 2010, did this person receive any income from the following sources?

Answer "yes" or "no" for all sources. If "yes," also enter the amount; in case of a loss, also mark "loss."

(a) Did this person receive any wages or salaries from paid employment?

Include commissions, bonuses, tips, taxable benefits, research grants, royalties, etc.
Report total amount before any deductions.

[] Yes: $_, _ _ _, _ _ _.00
[] No

(b) Did this person make a profit or loss from farm self-employment activities in 2010?
Report gross receipts minus expenses and capital cost allowance.

[] Yes: $_, _ _ _, _ _ _.00
[] No
[] Loss

(c) Did this person make a profit or loss from non-farm self-employment activities in 2010, such as trapping, making handicrafts, running a business or from professional practice?

Report gross receipts minus expenses.

[] Yes: $_, _ _ _, _ _ _.00
[] No
[] Loss

[Page 32]

[Remember, these questions are only for persons age 15 years and over]

(d) Did this person receive any child benefits from federal, provincial or territorial governments?

Include amounts such as child tax benefits, universal child care benefits and family allowances.

[] Yes: $_, _ _ _, _ _ _.00
[] No

(e) Did this person receive any Old Age Security Pension, Guaranteed Income Supplement, Allowance or Allowance for the Survivor from the federal government?

Provincial income supplements should be reported in (h).

[] Yes: $_, _ _ _, _ _ _.00
[] No

(f) Did this person receive any benefits from the Canada or Quebec Pension Plan?

[] Yes: $_, _ _ _, _ _ _.00
[] No

(g) Did this person receive any benefits from Employment Insurance from the federal government or the Quebec Parental Insurance Plan?

Include maternity and parental benefits.
Report total benefits before tax deductions.

[] Yes: $_, _ _ _, _ _ _.00
[] No

(h) Did this person receive any other income from government sources?

Include income such as provincial income supplements and grants, the GST/QST/HST credit, provincial tax credits, workers' compensation, veterans' pensions, and welfare payments.

[] Yes: $_, _ _ _, _ _ _.00
[] No

(i) Did this person receive any dividends, interest on bonds, deposits and savings certificates, or other investment income?

Include income such as net rents from real estate and interest from mortgages.

[] Yes: $_, _ _ _, _ _ _.00
[] No
[] Loss

(j) Did this person make any capital gains or losses?

Also include gains or losses from mutual funds. Do not include non-taxable capital gains on the sale of a principal residence. Report the full amount, not just the taxable portion.

[] Yes: $_, _ _ _, _ _ _.00
[] No
[] Loss

(k) Did this person receive any retirement pensions, superannuation or annuities?

Also include those from RRSPs and RRIFs. Do not include withdrawals from a pension plan or RRSP.

[] Yes: $_, _ _ _, _ _ _.00
[] No

(l) Did this person receive any other money income?

Include income such as treaty money, alimony, child support and scholarships.

[] Yes: $_, _ _ _, _ _ _.00
[] No

What was this person's total income in 2010 from all sources?

[] Yes: $_, _ _ _, _ _ _.00
[] No
[] Loss

What was the income tax paid on 2010 income (federal, provincial and territorial) for this person?

If none, enter "0."

$_, _ _ _, _ _ _.00

[Page 34]

Household questionnaire

Step E
Questions E1-E10 are about this dwelling.
The questions refer to May 10, 2011 unless otherwise specified.

A dwelling is a separate set of living quarters with a private entrance from the outside or from a common hallway or stairway inside the building. This entrance should not be through someone else's living quarters.

E1. Who pays the rent or mortgage, taxes, electricity, etc., for this dwelling?

If more than one person contributes to such payments, mark "x" as many circles as apply.

[] Person 1
[] Person 2
[] Person 3
[] Person 4
[] Person 5
[] A person who is listed on another questionnaire for this dwelling
[] A person who does not live here

E2. Only ask Question E2 (a) if you are in a First Nations community, an Indian reserve or an Indian settlement. Otherwise, go to Question E2 (b).

(a) Is this dwelling band housing, or rented, or owned by you or a member of this household?

[] Band housing [Go to question E3.]
[] Owned (even if it is still being paid for) [Go to question E3.]
[] Rented (even if no cash rent is paid) [Go to question E3.]

(b) Is this dwelling rented or owned by you or a member of this household?

[] Owned (even if it is still being paid for)
[] Rented (even if no cash rent is paid)

E3. Is this dwelling part of a condominium development?

[] Yes
[] No

E4 (a) How many rooms are there in this dwelling?

Include kitchen, bedrooms, finished rooms in attic or basement, etc.

Do not count bathrooms, halls, vestibules, attached sheds, porches and rooms used solely for business purposes.

Number of rooms: _ _

(b) How many of these rooms are bedrooms?

Include all rooms designed as bedrooms, even if they are now used for something else. Also include basement bedrooms.

Number of bedrooms: _ _

E5. When was this dwelling originally built?

Mark the period in which the building was completed, not the time of any later remodeling, additions or conversions. If year is not known, give best estimate.

[] 1920 or before
[] 1921-1945
[] 1946-1960
[] 1961-1970
[] 1971-1980
[] 1981-1985
[] 1986-1990
[] 1991-1995
[] 1996-2000
[] 2006-2011

E6. Is this dwelling in need of any repairs?

Do not include desirable remodeling or additions.

[] No, only regular maintenance is needed (painting, furnace cleaning, etc.)
[] Yes, minor repairs are needed (missing or loose floor tiles, bricks or shingles, defective steps, railing or siding, etc.)
[] Yes, major repairs are needed (defective plumbing or electrical wiring, structural repairs to walls, floors or ceilings, etc.)

[Page 38]

E7. Is this dwelling located on an agricultural operation that is operated by a member of this household?

[] Yes [Go to Step F on next page.]
[] No [Continue this section.]

Answer Questions E8 to E10 for this dwelling even if you own or rent more than one dwelling.
If the exact amount is not known, please give a best estimate.

[Questions E8-E10 were asked of dwellings not located on an agricultural operation that is operated by a member of this household, per question E7.]

E8. For this dwelling, what are the yearly payments (last 12 months) for:

(a) Electricity?

[] None
[] Included in rent or other payments
[] $ _, _ _ _.00 per year

(a) Oil, gas, coal, wood or other fuels?

[] None
[] Included in rent or other payments
[] $ _, _ _ _.00 per year

(a) Water and other municipal services?

[] None
[] Included in rent or other payments
[] $ _, _ _ _.00 per year

If "band housing" was checked in question E2 (a), go to step F on next page.
If "rented" was checked in question E2 (a) or E2 (b), continue with question E9.
If "owned" was checked in question E2 (a) or E2 (b), go to question E10.

E9. For renters only, answer parts (a) and (b):

(a) What is the monthly rent paid for this dwelling?

[] Rented without payment of cash rent
[] $ _, _ _ _.00 per month

(b) Is this dwelling subsidized?

Subsidized housing includes rent geared to income, social housing, public housing, government assisted housing, non-profit housing, rent supplements, and housing allowances.

[] Yes
[] No

E10. For owners only, answer parts (a) through (e):

a) What are the total regular monthly mortgage or loan payments for this dwelling?

[] None. [Go to part (c)]
[] $ _, _ _ _.00 per month

(b) Are the property taxes (municipal and school) included in the amount shown in part (a)?

[] Yes. [Go to part (d).]
[] No.

(c) What are the estimated yearly property taxes (municipal and school) for this dwelling?

[] None
[] $ _ _, _ _ _.00 per year

(d) If you were to sell this dwelling now, for how much would you expect to sell it?

$ _, _ _ _ , _ _ _.00

(e) What are the monthly condominium fees?

[] None.
[] $ _, _ _ _.00 per month

Note: Turn the page to step F.

[Page 39]

Step F

F1. This question is for all persons including children younger than 15.

Only if you mark "yes" to this question will your National Household Survey responses and family history be part of the historical record of Canada. A "yes" means your responses will be available to family members and historical researchers, 92 years after the 2011 National Household Survey, in 2103.

If you mark "no" or leave the answer blank, your responses will never be made available to future generations.

Does this person agree to make his or her 2011 National Household Survey information available in 2103 (92 years after the National Household Survey)?

Person 1
[] Yes
[] No
Person 2
[] Yes
[] No
Person 3
[] Yes
[] No
Person 4
[] Yes
[] No
Person 5
[] Yes
[] No

Step G

Comments: ____

[Page 40]