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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______

A. Localization

1. Department [département] ____

2. Municipality [commune] ____

3. City/neighborhood [ville/quartier] ____

Street____
Street Number____
Municipal section [section communale] ____

4. Census zone [section d'énumération] (SDE) ____

5. Supervision district ____

6. Plantation or village (habitation) ____

7. Town [localité] ____

8. Census zone rank _ _ _ _ _

9. Building number/Premises used for individual dwelling
REC: _ _ _ - _ _

10. Indicate the General Census of the Population and Dwelling numbers if relevant

1 _ _ _ _ _
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

[] 01 Mud hut or mud-floored hut [Kay atè] (roof and walls are not distinct)
[] 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?

[] 01 Wood/planks
[] 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?

[] 01 Slate
[] 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?

[] 01 Wood/planks
[] 02 Beaten earth
[] 03 Cement
[] 04 Mosaics
[] 05 Ceramic/tile [terrazzo]
[] 06 Marble
[] 07 Other

5. What state is the building in?

[] 1 Completed
[] 2 Under construction
[] 3 In ruins

6. Is the building:

[] 1 Permanently occupied
[] 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? _______

8.1 For collective/shared housing _ _
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.

[] 01 Prison
_ _ _ Number of men
_ _ _ Number of women
[] 02 Police station
_ _ _ Number of men
_ _ _ Number of women
[] 03 Boarding School
_ _ _ Number of men
_ _ _ Number of women
[] 04 Place of worship (temple, church, peristyle, mosque, etc.)
_ _ _ Number of men
_ _ _ Number of women
[] 05 Hospital
_ _ _ Number of men
_ _ _ Number of women
[] 06 Hotel
_ _ _ Number of men
_ _ _ Number of women
[] 07 Boarding house/university
_ _ _ Number of men
_ _ _ Number of women
[] 08 Other (please specify) ____
_ _ _ Number of men
_ _ _ 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:

[] 1 Occupied by a household
[] 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?

[] 1 Yes, inside
[] 2 Yes, in the yard/courtyard
[] 3 No

13. How is water typically obtained in this housing unit?

13.1 Drinking water
[] 01 Faucet (distribution service)
[] 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
13.2 General use
[] 01 Faucet (distribution service)
[] 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).

[] 01 Electricity (network)
[] 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?

[] 01 City truck
[] 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)

[] 01 Wood/straw
[] 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?

[] 1 Flush toilet
[] 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.]

[] a. Telephone
[] 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?

[] 01 Owner of land and house
[] 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

[] 01 Single household
[] 02 Multiple household (a group of persons living together)

21. How many "resident persons" make up this household?

Total _ _
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)

[For each person in household, beginning with the household head, the following information is filled in.]
Last and first name ____
Sex
[] 1 M
[] 2 W
Age _ _ _

[Instructions to enumerator on handling households with more than 8 people omitted.]

E. Deaths in the household

23. Were there any deaths in the household between __________, 2001 and ______________, 2002?

[] 1 Yes (if yes, how many?____)
[] 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.

Name ____
Sex
[] 1 Male
[] 2 Female
Age at death (000 for less than 1 year) _ _ _


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 ____

2. Person number: _ _

3. What is the relation of this person to head of household?

[] 01 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?

[] 1 Male
[] 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?

[] 1 Yes
[] 2 No
[] 3 Don't know

7. Is the mother of this person still alive?

[] 1 Yes
[] 2 No
[] 3 Don't know

8. Is this person the mother's oldest child currently living in Haiti?

[] 1 Yes
[] 2 No
[] 3 Don't know

9. What is this person's current religion?

[] 01 None
[] 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)

[] 01 No disability
[] 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?

[] 01 Here (the same city, same district or same municipal sector [section communale])
[] 02 Elsewhere in Haiti
Municipality____
City/district_____
Municipal sector____
[] 03 In another country
Country____

12. How long has this person lived in this city, this district or this municipal sector?

[] 01 Since birth
[] 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?

[] 01 Here (the same town, same district or same municipal sector [section communale])
[] 02 Elsewhere in Haiti
Municipality ____
City/district____
Municipal sector____
[] 03 In another country
Country____
_ _ _ _ _

14. Does this person know how to read and write?

[] 1 Yes
[] 2 No

15. What is the highest level of education attained by this person?

[] 01 None (go to question 17)
[] 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?

[] 1 Yes
[] 2 No (go to question 19)

18. What did this person study?

[Question 18 was asked of people who reported having taken classes in a National Center for Technical and Professional Training (per question 17).]
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.)

[] 01 Yes, academic institution/university
[] 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).]

1. Academic institution/university
[] 1 Private
[] 2 Public
2. Center for technical and professional training
[] 1 Private
[] 2 Public
3. Literacy center
[] 1 Private
[] 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:

[] 01 Single
[] 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 ______________?

[] 01 Worked (go to question 24)
[] 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 _______________.

[] 1 Yes
[] 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?

[] 1 Public sector
Private sector
[] 2 Household
[] 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:

[] 01. Owner/ boss [patron]
[] 02. Employee
[] 03. Independent
[] 04. Family helper
[] 05. Apprentice
[] 06. Other

28. What is this person's principal place of employment?

[] 01 Farm
[] 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?

[] 1 Yes
[] 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?

Month _ _
Year_ _ _ _

33. Is this last-born living child still alive?

[] 1 Yes (go to the next person)
[] 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).]

Month _ _
Year _ _ _ _

Notes ________

[Section containing verification questions for the enumerator is omitted.]