Republic of Haiti
Ministry of the Economy and Finance (MEF)
Haitian Institute of Statistics and Information Science (IHSI)
Census of the general population and dwelling
Form number ____
Sequence _______ of ________
Questionnaire number______
1. Department [département] ____
2. Municipality [commune] ____
3. City/neighborhood [ville/quartier] ____
Street Number____
Municipal section [section communale] ____
4. Census zone [section d'énumération] (SDE) ____
6. Plantation or village (habitation) ____
9. Building number/Premises used for individual dwelling
REC: _ _ _ - _ _
10. Indicate the General Census of the Population and Dwelling numbers if relevant
2 _ _ _ _ _
3_ _ _ _ _
4_ _ _ _ _
5_ _ _ _ _
6_ _ _ _ _
7_ _ _ _ _
8_ _ _ _ _
B. Building
(Fill out questions 1-8 only once for each building)
[Questions 1-8 were reported for each household.]
1. Specify the type of building
[] 02 Hut/hovel [taudis]
[] 03 Traditional circular dwelling/hut [ajoupas]
[] 04 Single-story house (simple)
[] 05 Multi-story house
[] 06 Apartment building
[] 07 Colonial-type building (gingerbread)
[] 08 Villa
[] 09 Other
2. What is the main building material of the walls?
[] 02 Dirt
[] 03 Cement/cement blocks
[] 04 Sheet metal
[] 05 Cardboard/plastic
[] 06 Brick/stone/rock
[] 07 Wood slats [clisse]
[] 08 Other
3. What is the main building material of the roof?
[] 02 Thatch/straw
[] 03 Cement/concrete
[] 04 Sheet metal
[] 05 Plastic
[] 06 Tile
[] 07 Other
4. What is the main building material of the floor?
[] 02 Beaten earth
[] 03 Cement
[] 04 Mosaics
[] 05 Ceramic/tile [terrazzo]
[] 06 Marble
[] 07 Other
5. What state is the building in?
[] 2 Under construction
[] 3 In ruins
6. Is the building:
[] 2 Occasionally occupied (if so, go to a different building)
[] 3 Vacant (if so, go to a different building)
[Questions 7 and 8 were asked of permanently occupied dwellings.]
7. How many premises not intended for habitation does this building have? _ _
8. How many premises does this building have? _______
8.2 For individual housing _ _
C. Premises used for collective/shared housing
[Questions 9.01 to 9.08 were asked of collective or shared housing premises only.]
9. Check the type of premises used for collective/shared housing and indicate the number of men and women in the box provided.
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
_ _ _ Number of women
(Go to the next premises or building)
D. Premises used for individual housing or "housing unit" [Unité d'habitation]
(Space intended for household dwelling)
[Questions 10-22 were asked of households that were not collective or shared housing.]
10. Is this premise:
[] 2 Vacant (go to a different housing unit or a different building)
11. How many rooms are there in this housing unit? _ _
12. Is this housing unit connected to a water distribution point?
[] 2 Yes, in the yard/courtyard
[] 3 No
13. How is water typically obtained in this housing unit?
[] 02 Public fountain
[] 03 Bought from truck
[] 04 Treated water
[] 05 Bought in large 5-gallon containers [boquite]
[] 06 River
[] 07 Spring
[] 08 Rain
[] 09 Ordinary well
[] 10 Artesian well
[] 11 Other
[] 02 Public fountain
[] 03 Bought from truck
[] 04 Treated water
[] 05 Bought in large 5-gallon containers [boquite]
[] 06 River
[] 07 Spring
[] 08 Rain
[] 09 Ordinary well
[] 10 Artesian well
[] 11 Other
14. What type of lighting is used in the housing unit? (Check off as many boxes as apply).
[] 02 Generator (delco)
[] 03 Solar panel
[] 04 Kerosene lamp
[] 05 Electric lamp
[] 06 Candles
[] 07 Other (please specify) ____
15. What is the principal type of solid-waste disposal?
[] 02 Collected by a private service
[] 03 Thrown onto empty lot
[] 04 Thrown into a ravine
[] 05 Thrown into the sewer
[] 06 Thrown into the street
[] 07 Thrown into the sea
[] 08 Periodic burning
[] 09 Other
16. What is the fuel source for cooking? (Check off as many boxes as apply)
[] 02 Propane gas
[] 03 Electricity
[] 04 Wood coal
[] 05 Kerosene
[] 06 Solar oven
[] 07 Other (please specify) ____
17. What type of toilet facilities does this housing unit have available?
[] 2 Individual latrine
[] 3 Shared latrine
[] 4 A hole in plot of land (la parcelle)
[] 5 None
18. What goods and equipment are used in this housing unit?
[Box is checked if item is used in housing unit.]
[] b. Radio (receiver)
[] c. Radio (communication)
[] d. Television
[] e. Refrigerator
[] f. Electric or gas oven
[] g. Sewing machine
[] h. Inverter
[] i. Washing machine
[] j. Computer
[] k. Fan
[] l. Machete
[] m. Shovel
[] n. Wheelbarrow
[] o. Motorcycle
[] p. Bicycle
[] q. Automobile
[] r. Hoe
[] s. Plow
[] t. Work animals
19. In what capacity does the household occupy this housing unit?
[] 02 Owner of the house only
[] 03 Renter
[] 04 Farmer
[] 05 Lives in house rent free
[] 06 De facto occupant
[] 07 Other
20. Type of Household
[] 02 Multiple household (a group of persons living together)
21. How many "resident persons" make up this household?
Men_ _
Women_ _
22. Indicate the name, sex and age of all "resident persons" who make up this household (Be insistent in getting information about babies and the elderly to add to the list)
Last and first name ____
Sex
[] 2 W
[Instructions to enumerator on handling households with more than 8 people omitted.]
23. Were there any deaths in the household between __________, 2001 and ______________, 2002?
[] 2 No (go to module 1)
[If there have been no deaths in the household in the past year, skip question 24.]
24. Indicate the name, sex and age (even if only approximate age) of each person who died in the household between ________________, 2001 and _____________, 2002.
Sex
[] 2 Female
E. Individual information
This section should be filled out for each person residing in the housing unit.
[Questions F1.1 through F1.12 were asked for all persons in each household.]
F1. For all Members of the household
1. Last name and first name ____
3. What is the relation of this person to head of household?
[] 02 Spouse, long-term extra-marital partner [concubin(e)]
[] 03 Son/daughter
[] 04 Father/mother
[] 05 Grandson/granddaughter
[] 06 Father-in-law/mother-in-law
[] 07 Son-in-law/daughter-in-law
[] 08 Other relative
[] 09 Employee (domestic)
[] 10 Child taken in as a domestic employee [enfant en domesticité]
[] 11 Other
4. What is the sex of this person?
[] 2 Female
5. How old is this person on the day of the census? (Write 000 if less than one year)
_ _ _
6. Does this person have his/her birth certificate?
[] 2 No
[] 3 Don't know
7. Is the mother of this person still alive?
[] 2 No
[] 3 Don't know
8. Is this person the mother's oldest child currently living in Haiti?
[] 2 No
[] 3 Don't know
9. What is this person's current religion?
[] 02 Catholic
[] 03 Adventist
[] 04 Jehovah's Witness
[] 05 Baptist
[] 06 Methodist
[] 07 Episcopal
[] 08 Pentecostal
[] 09 Voodoo
[] 10 Muslim
[] 11 Mormon
[] 12 Other
10. Does this person have a disability? (Check off as many boxes as apply)
[] 02 Blind
[] 03 Deaf
[] 04 Mute
[] 05 Upper limbs
[] 06 Lower limbs
[] 07 Mentally retarded
[] 08 Mental illness [problème mental]
[] 09 Other
11. Where was this person born?
[] 02 Elsewhere in Haiti
City/district_____
Municipal sector____
12. How long has this person lived in this city, this district or this municipal sector?
[] 02 Less than one year
[] 03 One to four (1-4) years
[] 04 Five to nine (5-9) years
[] 05 Ten (10) years or more
[] 06 Don't know
F2. Population aged 5 and older
[Questions F2.13 through F2.20 were asked for persons 5 years of age and older.]
13. Where was this person living in December 1997?
[] 02 Elsewhere in Haiti
City/district____
Municipal sector____
_ _ _ _ _
14. Does this person know how to read and write?
[] 2 No
15. What is the highest level of education attained by this person?
[] 02 Pre-school
[] 03 Primary school: 1st-2nd cycle [primaire/fond 1-2e cycle]
[] 04 Secondary school: 6th through 4th [secondaire (6-4)/fond 3e cycle]
[] 05 Secondary (3rd year to final year) [3e à philo]
[] 06 University 1st cycle [ler cycle]
[] 08 University 2nd cycle [2e cycle]
[] 09 University 3rd cycle [3e cycle]
[] 10 Other
16. What is the last year or class finished at this level? ____
17. Has this person taken classes in a National Center for Technical and Professional Training?
[] 2 No (go to question 19)
18. What did this person study?
1. In college/university____
2. At the National Center for Technical and Professional Training____
19. Has this person attended an academic institution/university/ National Center for Technical and Professional Training or a literacy center during the 2001-2002 academic year? (Check as many boxes as apply.)
[] 02 Yes, technical and professional training center
[] 03 Yes, literacy center
[] 04 No (go to question 21) [If no, skip question 20]
20. What type of academic institution or center for technical and professional training or literacy center did this person attend during the 2001-2002 academic year? (Check as many boxes as apply.)
[Question 20 was asked of persons who had attended an academic institution/university/ National Center for Technical and Professional Training or a literacy center during the 2001-2002 academic year (per question 19).]
[] 2 Public
[] 2 Public
[] 2 Public
F3. Population aged 10 and older
[Questions 21-28 were asked for individuals 10 years of age and older.]
21. Is this person currently:
[] 02 Married
[] 03 Cohabiting (with legal rights for children born of the couple) [placé(e)]
[] 04 Living with someone [viv avèk]
[] 05 Divorced
[] 06 Widowed
[] 07 Separated (from marriage)
[] 08 Separated (from cohabitation)
22. What did this person do from __________ to ______________?
[] 02 Did not work but had a job (go to question 24)
[] 03 Looked for work having previously had a job
[] 04 Looked for work not having previously had a job
[] 05 Did not work because discouraged
[] 06 Studied only
[] 07 Is retired, receives a pension or a private income
[] 08 Took care of home only
[] 09 Is an invalid
[] 10 Other
23. Did this person have any type of employment/economic activity in the period between ______________ and _______________.
[] 2 No (go to section F4)
24. What is the principal type of goods produced or services provided by the company where this person worked (or by the person him/herself if this person is independent)?
____
25. What is this person's principal job in this company?
____
26. Who did this person work for?
Private sector
[] 3 Cooperative
[] 4 Non-governmental organization
[] 5 For himself/herself
[] 6 Other (please specify) ____
27. In what capacity does this person work in this job:
[] 02. Employee
[] 03. Independent
[] 04. Family helper
[] 05. Apprentice
[] 06. Other
28. What is this person's principal place of employment?
[] 02 Factory/workshop/construction site
[] 03 Store, office
[] 04 At home
[] 05 At the employer's home
[] 06 In the street/arcade [galérie]/sidewalk
[] 07 Garage
[] 08 Market
[] 09 Taxi, transportation vehicle
[] 10 Other (please specify)____
F4. Female population aged 13 and older
[Questions 29-34 were asked of women who were 13 years of age or older.]
29. Has this person already given birth to a living child?
[] 2 No (go to the next person)
30. How many children born alive has this person had in total? ____
31. How many of these children are still alive? ____
32. What is the date of birth of the last child who was born alive?
Year_ _ _ _
33. Is this last-born living child still alive?
[] 2 No
[If yes, skip question 34]
34. On what date did this last-born living child die?
[Question 34 was asked of women age 13 and older whose last-born living child is no longer alive (per question 33).]
Year _ _ _ _
[Section containing verification questions for the enumerator is omitted.]