Republic of Indonesia
Population Census 1971

Form E

Household characteristics (short form)

[] Urban
[] Rural

Location code

1. Province ____
2. Regency/municipality ____
3. Sub-district ____
4. Village or the like ____
5. Census block number ____
6. Number of building ____

7. Serial number of household

a. Private ____
b. Institutional ____

8. Address ____

Household characteristics

1. Serial number ____
2. Name of the head of the household and members ________

Age and sex

0-4

[] 3 Male
[] 4 Female

5-14

[] 5 Male
[] 6 Female

15-24

[] 7 Male
[] 8 Female

25 and over

[] 9 Male
[] 10 Female

Citizenship

Indonesian

[] 11 Male
[] 12 Female

Foreigner

[] 13 Male
[] 14 Female

Total _ _

II. Household and living unit information

A. Province ____

B. Regency/municipality ____

C. Sub-district ____
D. Village or the like ____

E. Serial number of census block ____

F. Number of census building ____

Location identification and code ____

1. Sample block code _ _ _ _

2. Serial number of household _ _ _

3. Total number of household members _ _

Household and living unit information

Name of head of household and names of all other persons who usually live or stay here.

Be sure to include infants and persons who are staying more than 6 months

1. Serial number ____
2. Name of household head and household members ________
3. Relationship to head ____
4. Date of birth ____
5. Age ____

1. Is this living unit

[] Owned
[] Contracted
[] Rented
[] Rent to purchase
[] Property of government
[] Other

2. Does this household occupy

[] Entire housing unit
[] Part of housing unit
[] Part of shop/school/office, etc.
[] Other

3. How many rooms are there?

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10

4. Exterior wall material

[] Masonry
[] Wood
[] Bamboo
[] Other

5. What is roof made of?

[] Concrete
[] Wood
[] Zinc
[] Tile
[] Palm leaves
[] Other

6. What is floor made of?

[] Earthen tile
[] Cement/brick
[] Wood
[] Bamboo
[] Earth
[] Other

7. What kind of lighting/lamp is used?

[] Electric
[] Kerosene
[] Other

8. What kind of fuel is used for cooking?

[] Electric
[] Gas
[] Kerosene
[] Wood/charcoal
[] Other

9. Drinking water is from

[] Pipe
[] Pump
[] Well
[] Spring
[] River
[] Rain
[] Other

10. Location of drinking water facility

[] Inside yard
[] Outside yard

11. Water for other uses is from

[] Pipe
[] Pump
[] Well
[] Spring
[] River
[] Rain
[] Other

12. Toilet facility

[] Private
[] Shared
[] Public
[] Other

13. Type of toilet

[] Flush
[] Not flush

14. Type of garbage disposal [garbage piling place]

[] Tub/barrel
[] Hole
[] Other

15. Procedure to throw away garbage

[] Carried
[] Burned
[] Buried
[] Other

Individual form
[Section I is the same as Section I: Household and Living Unit Information above]

II. For all ages

1. Sex

[] Male
[] Female

2. Age

_ _
[] 100 100 or older

3. Relationship to head of household

[] Head
[] Spouse
[] Son/daughter
[] Son/daughter-in-law
[] Grandson/granddaughter
[] Father/mother
[] Father/mother-in-law
[] Other family
[] Servant
[] Other

4. Marital status

[] Single
[] Married
[] Divorced
[] Widow/widower

5. Citizenship

[] Indonesia
[] China
[] Arabian country
[] India
[] Pakistan
[] Other

6. Religion

[] Islam
[] Catholic
[] Protestant
[] Other Christian
[] Hindu
[] Buddhist
[] Kong Fhu Tse [Confucianism]
[] Other

7. Language

[] Indonesian
[] Regional/local
[] Other

8. Ability to read and write

[] Latin characters
[] Arabic
[] Chinese
[] Other
[] Illiterate

9. Highest grade completed

General (skip to question 11)

[] None
[] Not completed [elementary school]
[] Elementary school
[] Junior high school
[] High school

Vocational

[] Junior high school
[] High school

[] Academy
[] University

10. Field of education

[Question 10 was asked of persons who have completed vocational, academy or university study, per question 9]

[] Agriculture
[] Technical
[] Communications
[] Health
[] Teaching
[] Other

11. Are you still attending school?

[] Yes
[] No

12. Place of birth

[] 1 Aceh
[] 2 North Sumatra
[] 3 West Sumatra
[] 4 Riau
[] 5 Jambi
[] 6 South Sumatra
[] 7 Bengkulu
[] 8 Lampung
[] 9 Jakarta (DKI Jaya)
[] 10 West Java
[] 11 Central Java
[] 12 Yogyakarta (DI Yogyakarta)
[] 13 East Java
[] 14 Bali
[] 15 West Nusa Tenggara
[] 16 East Nusa Tenggara
[] 17 West Kalimantan
[] 18 Central Kalimantan
[] 19 South Kalimantan
[] 20 East Kalimantan
[] 21 North Sulawesi
[] 22 Central Sulawesi
[] 23 South Sulawesi
[] 24 Southeast Sulawesi
[] 25 Maluku
[] 26 Irian Jaya
[] 29 Abroad

13 Did you ever live in another province?

[] Yes
[] No (Do not answer questions 14 and 15)

[Questions 14-15 were asked of persons who have ever lived in another province, as per question 13]

14. Province of previous residence

15. Total years lived in present province

_ _

Married/ever-married women

1. Number of children still alive

a. As household member _ _
b. Not as household member _ _

Total _ _

2. Number of children dead _ _

3. Number of children born alive _ _

16. Number of children born alive _ _

17. Number of children still alive _ _

IV. 10 years or older

18. Did you do any work last week?

[] Yes (skip to question 21)
[] No

19. What were you doing last week?

[Question 19 was asked of persons age 10 or older who did not work last week, per question 18]

[] Looking for work
[] School (skip to question 24)
[] Household [duties] (skip to question 24)
[] Retired (skip to question 24)
[] Other (skip to question 24)

20. Did you ever do any work?

[Question 20 was asked of persons age 10 or older who did not work last week but are looking for work, per questions 18 and 19]

[] Yes
[] No (skip to question 24)

[Questions 21-23 were asked of persons age 10 or older who had either worked last week, or have ever worked before and were looking for work last week, per questions 18, 19 and 20.]

21. Occupation status

[] Own account
[] Employer
[] Employee
[] Unpaid family worker

22. Occupation (write completely)

________

23. Industry (write completely)

________

24. Did you work in agriculture last season?

[] Yes
[] No (end the interview for this person)

25. Occupational status [agriculture]

[Question 25 was asked of persons age 10 or older who worked in agriculture last season, per question 24.]

[] Own account
[] Agricultural employee
[] Employer
[] Unpaid family worker

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