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Dominican Republic
Ministry of Economy, Planning and Development
National Office of Statistics

IX National Population and Housing Census 2010

ONE - National Office of Statistics, according to law 5096 of March 6th, 1959, all information solicited is strictly confidential

Instructions
Only use provided pencil to fill in the bubbles of the survey. Only write in capital letters. Do not mark accents nor cross or erase, write with clear letters and numbers.

[Examples of how to fill in the circles are omitted]

Section I - Geographic location

Folder Number: _ _ _ _ _ _

Surveyed housing number: _ _ _

Household number within dwelling: _

Neighborhood/region: ____

Block: _ _ _ _

If this survey is a continuation of the previous one please fill in:

[] Continuation

Household address: ________ (street, avenue, path, road, km, etc.)

House No.____ Apt. No. ____

Section II - Dwelling characteristics

1. Dwelling type:

Observe and record

Private dwellings
[] 1 Independent house
[] 2 Apartment
[] 3 Room in a bunkhouse or in the back of the premises
[] 4 Room in barracón
[] 5 Housing shared with business
[] 6 Premises not intended for habitation
[] 7 Other type of private dwelling
Collective dwellings
[] 8 Hotel, pension or guesthouse (go to Section V)
[] 9 Military quarters (go to Section V)
[] 10 Prison (go to Section V)
[] 11 Hospital or health center (go to Section V)
[] 12 Religious institution or boarding school (go to Section V)
[] 13 Other type of collective household (go to Section V)
[] 14 Homeless (go to Section V)

2. This dwelling is:

Observe and record

[] 1 Occupied with residents
[] 2 Occupied with absent residents (go to next house and return later)
[] 3 Vacant (fill in questions 3 and 4 and go to the next house)

Remember that if the dwelling is occupied, but with absent residents, you should return to it later.

3. What is the main material of the exterior walls of this dwelling?

[] 1 Concrete or concrete block
[] 2 Wood
[] 3 Palm planks
[] 4 Wood planks
[] 5 Palm leaves
[] 6 Other

4. What is the main material of the roof of this dwelling?

[] 1 Concrete
[] 2 Tin
[] 3 Asbestos cement
[] 4 Reeds
[] 5 Palm leaves
[] 6 Other

5. What is the main material of the floor of this dwelling?

[] 1 Tile
[] 2 Cement
[] 3 Granite
[] 4 Marble
[] 5 Ceramic
[] 6 Wood
[] 7 Dirt
[] 8 Other

6. Does this dwelling have a kitchen or cooking room either inside or outside the house?

[] 1 Yes, inside the dwelling
[] 2 Yes, outside the dwelling
[] 3 No

7. How many rooms does the dwelling have, not counting bathrooms, kitchen, hallways or garage?

Number of total rooms _ _

Section III - Household identification

Read to the interviewee: A household is a single person or group of people that share food and living expenses and live under the same roof.

8. So, how many households are in this dwelling?

[] 1 (If there is one (1) household, go to question 9)
[] 2
[] 3
[] 4
[] 5
[] 6 or more

[If there is more than one household] use one survey per household and proceed this way:
A) Fill in the survey of the first home
B) Use a new survey for each additional home and fill in section I geographical location and leave blank sections II and III, then continue filling in sections IV, V and VI

Section IV - Household characteristics

9. Which of the following articles or services does your household have?

Read slowly all the possible answers, and fill in "yes" or "no' accordingly.


a. Stove?
[] 1 Yes
[] 2 No

b. Refrigerator?
[] 1 Yes
[] 2 No

c. Washing machine?
[] 1 Yes
[] 2 No

d. Television?
[] 1 Yes
[] 2 No

e. Radio/stereo?
[] 1 Yes
[] 2 No

f. Cistern?
[] 1 Yes
[] 2 No

g. Water tank?
[] 1 Yes
[] 2 No

h. Computer?
[] 1 Yes
[] 2 No

i. Internet?
[] 1 Yes
[] 2 No

j. Converter?
[] 1 Yes
[] 2 No

k. Generator?
[] 1 Yes
[] 2 No

l. Landline?
[] 1 Yes
[] 2 No

m. Does any member of the household have a cellphone?
[] 1 Yes
[] 2 No

n. Air conditioning?
[] 1 Yes
[] 2 No

ñ. Motor?
[] 1 Yes
[] 2 No

o. Own car?
[] 1 Yes
[] 2 No

10. This household (or part of it) is:

Read all answers and mark only one.

[] 1 Owned, paid off?
[] 2 Owned, paying mortgage?
[] 3 Rented?
[] 4 Given or lent?
[] 5 Other?

11. How many rooms (bedrooms) are in this household?

Number of bedrooms _ _

12. What kind of toilet facility does your household have?

[] 1 Toilet
[] 2 Latrine
[] 3 None (skip to question 14)

13. Does your household share a bathroom with other households?

[] 1 It is used only by household members
[] 2 It is shared with other households

14. How does the garbage get disposed of in this household?

[] 1 Collected by public sanitation service
[] 2 Collected by private sanitation service
[] 3 Burned
[] 4 Thrown in the backyard or lot
[] 5 Put in the garbage dump
[] 6 Thrown in the river or ravine
[] 7 Other


15. What is the principal source of water used to wash, scrub, shower, etc. in this household?

[] 1 Water conduit inside of the house
[] 2 Water conduit on patio
[] 3 A neighbor's tap
[] 4 Public tap
[] 5 Pipe from the street
[] 6 Spring, river, stream
[] 7 Rainwater
[] 8 Well
[] 9 Water truck
[] 10 Other

16. What type of fuel does your household mainly use for cooking?

[] 1 Propane
[] 2 Coal
[] 3 Wood
[] 4 Electricity
[] 5 Other
[] 6 Never cooks


17. What type of electricity does your household use?

[] 1 Public electricity
[] 2 Propane lamp
[] 3 Kerosene lamp
[] 4 Electricity from own generator
[] 5 Other

Mortality

18. Including all newborn babies and elderly people, has any household member has died as of 2009, meaning between January 1st and December 31st of 2009?

[] 1 Yes
[] 2 No (go to question 19)
Name
01: ____
02: ____
03: ____

18a. What is the sex of [this person]?

[] 1 Male
[] 2 Female

18b. When did [this person] die?

_ _ Day
_ _ Month

18c. How old was [this person] when he/she died?

If less than 1 year of age record '00' _ _ _

Agricultural production

19. Do any of the members of this household have sown field, uncultivated land, fallow land (either owned, rented or half-half, etc.) or have they harvested within the last 12 months?

[] 1 Yes (record the information of the person(s)
[] 2 No (go to question 20)
Name of person: ____

How many tareas…
_ _ _ _ Does [the respondent] have sown land?
_ _ _ _ Did [the respondent] harvest in the last 12 months?

20. Do any of the members of this household have animals for household consumption or for sale?

[] 1 Yes
[] 2 No (go to question 21)
Name of person: ____

How many…
_ _ _ _ Cows, bulls, calves and oxen does [the respondent] have?
_ _ _ _ Ducks, turkeys, geese does [the respondent] have?
_ _ _ _ Hens, chickens, roosters does [the respondent] have?
_ _ _ _ Bees does [the respondent] have?
_ _ _ _ Pigs does [the respondent] have?
_ _ _ _ Goats, sheep, rabbits does [the respondent] have?

Section V - List of household members

Order number [01, 02, 03, 04, 05, 06... 20]

21. Please give all the names of the permanent residents of this household, starting with the head of household: ____

22. Sex

Record 'M' if male or 'F' if female

[] Male
[] Female

Circle the order number of the interviewee or the person that provides the data

23. Is there a newborn or child that was not included?

[] 1 Yes (Record the information of the child or children in the chart above)
[] 2 No

24. Besides all people mentioned, is there any household member that is not present and is travelling for leisure, business, and study or has been in the hospital, etc.?

[] 1 Yes (Record the information of that person in the chart above)
[] 2 No

25. Household population summary

_ _ _ Male
_ _ _ Female
_ _ _ Total

Section VI - Personal characteristics

Number of person _ _ _
Name ____

For all residents

26. What is the relationship of [the respondent] to the head of household?

[] 1 Male or female head of household
[] 2 Spouse or partner
[] 3 Son/daughter
[] 4 Stepson/stepdaughter or foster son/daughter
[] 5 Father/mother
[] 6 Grandchild
[] 7 Father in law/mother in law
[] 8 Grandfather/grandmother
[] 9 Brother/sister
[] 10 Maid or household worker
[] 11 Other relative
[] 12 Son or daughter in law
[] 13 Other non-relative

27. Is [the respondent] male or female?

[] 1 Male
[] 2 Female


28. When was [the respondent] born?

Day_ _
Month_ _
Year _ _ _ _

29. How old is [the respondent]?

If less than one year, record 000

_ _ _ Years

30. Where was [the respondent] born?

[] 1 Here, in this municipality (Skip to question 34)
[] 2 In another municipality
[] 3 Abroad (Skip to question 32)

31. In which municipality of the Dominican Republic was [the respondent] born?

____ (Skip to question 34)

32. In which country was [the respondent] born?

____

33. In which year did [the respondent] arrive to the Dominican Republic?

Year of arrival to the Dominican Republic _ _ _ _

34. Does [the respondent] have permanent difficulty with any of the following?

Read slowly all the possible answers, and fill in every time there is a "yes" or "no" accordingly.


a. Seeing, even if he/she uses glasses?

[] 1 Yes
[] 2 No

b. Hearing, even if uses hearing aid?
[] 1 Yes
[] 2 No

c. Walking or climbing stairs?
[] 1 Yes
[] 2 No

d. Moving one or both arms?
[] 1 Yes
[] 2 No

e. Moving or both legs?
[] 1 Yes
[] 2 No

f. Remembering or concentrating?
[] 1 Yes
[] 2 No

g. Grasping objects and/or opening containers with his/her hands?
[] 1 Yes
[] 2 No

h. Speaking?
[] 1 Yes
[] 2 No

i. Is he/she mute?
[] 1 Yes
[] 2 No

j. Does he/she have mental problems?
[] 1 Yes
[] 2 No

k. Is he/she or missing one or both legs?
[] 1 Yes
[] 2 No

l. Is he/she or missing one or both arms?
[] 1 Yes
[] 2 No

For persons age 3 and over

35. Does [the respondent] know how to write and read?

[] 1 Yes
[] 2 No

36. Has [the respondent] attended school, high school or university?

[] 1 Yes, attends school
[] 2 Does not currently attend but attended school
[] 3 Never attended school

37. What is the highest level of school [the respondent] has attended: Preschool, primary/basic, secondary/high school, university?

[] 1 Preschool (skip to question 42)
[] 2 Primary/elementary
[] 3 Secondary/high school
[] 4 University or higher (skip to question 39)

38. What is the last level of school [the respondent] has completed?

Last year completed _ (skip to question 42)

39. What is/was the university course [the respondent] studied or studies?

____

40. Did [the respondent] complete his/her degree?

[] 1 Yes
[] 2 No

41. How many years did [the respondent] studied at the college, master's or doctorate level, including a specialty?

If less than one year, record 00 _ _

For people age five and older (check from question 29)

42. Where did [the respondent] reside in November 2005?

[] 1 Here, in this municipality (skip to question 45)
[] 2 In another municipality
[] 3 Abroad (skip to question 44)

43. In November 2005, in what municipality did [the respondent] live?

____ (skip to question 45)

44. In November 2005, in what country did [the respondent] live?

____

For persons age 10 or older

45. During the past week (seven days) has [the respondent] done any type of work in which he/she received any kind of payment, even if he/she was not working because of time-off, illness or other reason?

[] 1 Yes (skip to question 52)
[] 2 No

46. During the past week (seven days) has [the respondent] done any type of work for at least one hour such as selling food or clothes, sewing, motorcycle taxi, selling tickets, etc. in which he/she received any kind of payment?

[] 1 Yes (skip to question 52)
[] 2 No

47. During the past week did [the respondent] help in a business, farm or a family activity, in which he/she did not receive any remuneration?

[] 1 Yes (skip to question 52)
[] 2 No

48. During the last four weeks, has [the respondent] looked for a paid job or tried to establish his/her own business or company?

[] 1 Yes (skip to question 51)
[] 2 No

49. What has [the respondent] been doing during the last week?

[] 1 Household chores
[] 2 Studying
[] 3 Rentier
[] 4 Retired or receiving pension
[] 5 Not working due to disability
[] 6 Not working due to old age
[] 7 Other
[] 8 None

50. Last week, would [the respondent] have had the time and necessary conditions to get to work if he/she had been offered a job?

[] 1 Yes
[] 2 No

51. Has [the respondent] worked before for a remunerated work?

[] 1 Yes
[] 2 No (skip to question 55)

52. What was [the respondent]'s main occupation, last week (or in his/her last job)?

____

53. In that job [the respondent] was (or is)?

Read all answers and mark only one.

[] 1 Salary or waged employee?
[] 2 Employer or owner?
[] 3 Family worker or unpaid worker?
[] 4 Self-employed?
[] 5 Other?

54. What is the goal of the business, company or institution where [the respondent] works (or last worked)?

____

For people age 15 and older

55. Currently, is [the respondent]: (Read all answers and mark only one)

[] 1 Separated legally or religiously
[] 2 Divorced
[] 3 Widow/widower
[] 4 Separated from a civil union
[] 5 Married
[] 6 Living together
[] 7 Single (Never married or in a civil union)

For women age 15 and older (check from questions 27 and 29)

56. In total, how many live births has [the respondent] had, even if the baby died a few hours or days after being born?

If the interviewee has had children, record the number of children born. If the interviewee has had children of only one sex, record the total number and write "00" in the box corresponding to the other sex. If the interviewee has never had children, fill in the bubble "none", then go to the next person.
_ _ Female children
_ _ Male children

[] None (go to next person)

57. Of all the children, how many are currently living?

If none fill in the bubble "none".

_ _ Female children
_ _ Male children

[] None

58. In what month and year was the last child born alive of [the respondent]?

Month _ _
Year _ _ _ _

59. Is the last child of [the respondent] alive?

[] 1 Yes (go to the next person)
[] 2 No

60. How old was the child when he/she died?

If less than one year of age, record 00

Age _ _

[Person form is repeated six times]

Observations ________

Instructions
Only use provided pencil to fill in the bubbles of the survey. Only write in capital letters. Do not mark accents nor cross or erase, write with clear letters and numbers.

[Examples omitted.]

Name of interviewer: ____
Name of supervisor: ____