Central Bureau of Statistics
Intercensal Population Survey 1976
I. Information on location
1. Province ____
2. District ____
3. Sub-district ____ _
4. Village ____ _
5. Cluster no. ____
6. Census block no. ____
7. Building no. ____
8. Household no. ____ _ _ _
9. Address or location ____
II. Information on interviewer/supervisor
1. Name of interviewer ____
2. Date of interview ____
3. Name of supervisor ____
4. Date checked by supervisor ____
Ask of the head of household or other eligible respondent
What are the names of the members of this household?
Are there any other household members who have not yet been mentioned, such as:
1. Young children or new-born babies?
2. Household members who are temporarily away from home?
3. Other household members such as other relatives or servants who live with you?
If yes, enter their names.
____
Are you:
[] P Female
In what month and year were you born?
Month:
Western_ _
Islam/Java ____
Other____
Year:
Western_ _
Islam/Java ____
Other____
How old are you?
Are you currently:
[] 2 Married
[] 3 Widowed
[] 4 Divorced
[] 5 Separated
A6. Relationship to head of household
What is the name of the head of this household? What is the relationship of each person with the head of this household?
Fill in the code showing the relationship to the head of household.
[] 1 Head
[] 2 Wife of head
[] 3 Own child of head
[] 4 Non-own child of head
[] 5 Grand child
[] 6 Parent of head
[] 7 Parent of wife of head
[] 8 Son/daughter-in-law
[] 9 Other family
[] 0 Non-family such as servants, etc.
Does your mother live in this household, outside of this household, or is she already dead?
[] 2 Lives outside this household
[] 3 Already dead
[] 4 Don't know
If the mother lives in this household (code 1), write in mother's line [person] number: _ _
Phase II
[] K Urban
[] P Rural
I. Information on location
1. Province ____
2. District ____
3. Sub-district ____ _
4. Village ____ _
5. Cluster no. ____
6. Census block no. ____
7. Building no. ____
8. Household no. ____ _ _ _
9. Address or location ____
10. Total no. of household members _ _
Ask the head of household or other eligible respondent. Ask questions column by column.
What are the names of the members of this household?
Are there any other household members who have not yet been mentioned, such as:
1. Young children or new-born babies?
2. Household members who are temporarily away from home?
3. Other household members such as other relatives or servants who live with you?
If yes, enter their names.
____
A2. Sex
Are you:
[] P Female
A3. Date of birth
In what month and year were you born?
Month:
Year:
Western_ _
Islam/Java ____
Other____
A4. Age
How old are you?
A5. Marital status
Are you currently:
[] 2 Married
[] 3 Widowed
[] 4 Divorced
[] 5 Separated
A6. Relationship to head of household
What is the name of the head of this household? What is the relationship of each person with the head of this household?
Fill in the code showing the relationship to the head of household.
[] 1 Head
[] 2 Wife of head
[] 3 Own child of head
[] 4 Non-own child of head
[] 5 Grand child
[] 6 Parent of head
[] 7 Parent of wife of head
[] 8 Son/daughter-in-law
[] 9 Other family
[] 0 Non-family such as servants, etc.
A7. Religion
What religion do you follow?
[] 2 Catholicism
[] 3 Protestant
[] 4 Other Christian
[] 5 Hindu
[] 6 Buddhism
[] 7 Confucianism
[] 8 Other
A8. Are you still in school?
[] T No
A9a. What level of school are you currently attending?
[Question A9a was asked of persons still in school, per question A8.]
____
A9b. What level of school did you last attend?
[Question A9b was asked of persons not in school, per question A8.]
[] 1 Never attended school
[] 2 Elementary school
[] 3 Junior high - general
[] 4 Junior high - vocational
[] 5 Senior high - general
[] 6 Senior high - vocational
[] 7 Academy
[] 8 University
If ever/currently attending school, write in number of highest class ever/currently attended. If completed, write in code 8.
[Highest class]: _
A10. Literacy
Can you read and write in Latin characters?
If "No": Can you read and write in any other characters?
[] 1 Latin
[] 2 Other
[] 3 Unable to read and write
A11. Does your mother live in this household, outside of this household, or is she already dead?
[] 2 Lives outside this household
[] 3 Already dead
[] 4 Don't know
A12. If the mother lives in this household (code 1), write in mother's line [person] number.
A13a. Are you your mother's eldest child?
[] T No
A13b. Do you have any older brothers or sisters who are still living?
[Question A13b was asked of persons who are not the eldest of siblings, per question A13a.]
[] Y Yes
[] T No
A14. Does your father live in this household, outside of this household, or is he already dead?
[] 2 Lives outside this household
[] 3 Already dead
[] 4 Don't know
A15. If the father lives in this household (code 1), write in father's line [person] number.
A16. Place of birth
In which district (kabupaten/kotamadya) were you born?
Kabupaten or kotamadya? Cross incorrect answer.
Coded by central office: _ _ _
A17. Recent migration
Were you living in this district five years ago?
[] T No
If code Y, end section A for this person.
[Questions A17a and A17b were asked of persons not living in the same district five years ago]
A17a. In which village, sub-district, and district were you living in five years ago?
Write in the name of the village: ____
Was this village part of a city, a town, or a rural area?
[] K Town
[] P Rural area
Write in the name of the district: ____
Kabupaten or koyamadya? Cross incorrect answer.
A17b. What was the reason for your move?
[] 2 Transferred
[] 3 Other work-related reason
[] 4 School
[] 5 Marriage
[] 6 Following family
[] 7 Going home
[] 8 Other
B. Economic condition of the household
Ask the head of household or other eligible respondent. Circle the code of the correct answer.
B1. What is the means of livelihood for this household?
[] 2 Non-agriculture only
[] 3 Mixture, with agriculture the primary means
[] 4 Mixture, with non-agriculture the primary means
If the above is agriculture or mixture (B1 = code 1, 3, or 4) ask B2. If the above is non-agriculture (B1 = code 2) go to B3.
[Question B2 was asked of households that indicated some involvement in agriculture, per question B1.]
B2a. How much land do you farm?
B2b. Do you have any of the following animals in this household?
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
[] T No
If yes, how many? _ _
B2c. Do you use any of the following farming/fishing implements in your work?
[] 2 No
[] 2 No
[] 2 No
B3. What is the average monthly expenditure of this household?
B4. What is the main building material of the wall?
[] 2 Wood
[] 3 Bamboo
[] 4 Other: ____
B5. What is the main building material of the floor?
[] 2 Cement
[] 3 Wood
[] 4 Bamboo
[] 5 Earth
[] 6 Other: ____
B6. What is the main source of lighting for this household?
[] 2 Pump lamp
[] 3 Oil lamp
[] 4 Other: ____
B7. In what type of structure is this household located?
[] 2 Combined residence and business
[] 3 Room(s) in single living quarters
[] 4 Separate apartment
[] 5 Shared living quarters
[] 6 Row housing
[] 7 Other: ____
B8a. What is the source of bathing/washing water for this household?
[] 2 Electric pump
[] 3 Hand pump
[] 4 Private well
[] 5 Public well
[] 6 Spring
[] 7 River water
[] 8 Rain water
[] 9 Other: ____
B8b. Is this source located inside or outside the yard?
[] L Outside the yard
B9a. What is the source of drinking water for this household?
[] 2 Electric pump
[] 3 Hand pump
[] 4 Private well
[] 5 Public well
[] 6 Spring
[] 7 River water
[] 8 Rain water
[] 9 Other: ____
B9b. Is this source located inside or outside the yard?
[] L Outside the yard
B10. Does this household possess any of the following goods?
[] T No
[] T No
[] T No
[] T No
Ask the head of household or other eligible respondent. Circle the code of the correct answer.
C1. Seeing difficulties
Is there anyone in this household who has difficulty seeing so that he/she needs assistance in walking around outside during the daytime?
[] 2 No
C2. Mortality
Did any deaths occur in this household during the past two years, that is, from about January 1974 to the present time?
[] Y Yes
[] T No
If "No", go to section D. If "Yes", ask the following questions about each person who died:
[Questions C3-C7 were asked of households with at least one death during the past two years, per question C2.]
Can you tell me the name of the person who died?
Was this person male or female?
[] P Female
What was the relationship of this person to the current head of household?
How old was this person when he/she died?
In what month and year did this person die?
Western _ _
Islam/Java____
Other ____
Year:
Western _ _
Islam/Java____
Other ____
D. Information on economic activity
Ask of household members age 10 or older. Ask questions person by person.
D1-D2. Economic activity during the past week
D1. What was your primary activity during the past week?
[] 2 Temporarily away from work but with a job
[] 3 Looking for work
[] 4 Housekeeping
[] 5 Attending school
[] 6 Unable to work
[] 7 Other
If code 1, go to D3.
D2. Did you do any work for one hour or more during the past week?
[] Y Yes
[] T No
If D2 = code "T" go to D10. If D1 = code 3, go to D11.
D3-D7. Primary occupation during the past week
[Questions D3-D8 were asked of persons age 10 or older who worked at least one hour during the past week, as per questions D1 and D2.]
D3. Occupation
In what occupation was your primary job during the past week?
Coded by central office: _ _ _
D4. Industry
In what industry was that work?
Coded by central office: _ _
D5. Status
In this work were you a:
[] 2 Employer
[] 3 Employee
[] 4 Unpaid family worker
D6. Locus of activity
Was this work a:
[] 2 Non-household enterprise
D7. Hours worked
How many hours did you work last week at this job?
D8. Besides your primary job, did you do any other work during the past week?
[] T No
If code "T" go to D10, except if D1 = code 3 go to D11.
D9. If you had additional work last week, how many different kinds of additional work did you do?
Write in total number of jobs: _
If D1 = code 3 go to D11.
D10. Are you also looking for work?
[] Y Yes
[] T No
If D10 = code "T", go to D13. If D1 = code 1 or 2, go to D14.
[Questions D11-D12 was asked of persons age 10 or older who were looking for work during the past week.]
D11. For how many months have you been looking for work?
D12. What steps have you taken in looking for work?
[] 1 Asked family or friends
[] 2 Looked in the newspaper
[] 3 Applied to a factory or office
[] 4 Registered with an employment exchange
[] 5 Other
D13. If there was work available, would you want to take it?
[] Y Yes
[] T No
D14-20. Usual activity during the past year
D14. What was your usual activity during the past year?
[] 2 Looking for work
[] 3 Housekeeping
[] 4 Attending school
[] 5 Unable to work
[] 6 Other
If code "1", go to D16.
D15. Did you do any work for more than two months?
[] Y Yes
[] T No
If D15 = code "T", end Section D for this person.
[Questions D16-D19 were asked of persons age 10 or older who worked for at least two months during the past year.]
D16. Occupation
In what occupation as your usual job during the past year?
____
Coded by central office: _ _ _
D17. Industry
In what industry was that work?
____
Coded by central office: _ _ _
D18. Status
In this work were you a:
[] 2 Employer
[] 3 Employee
[] 4 Unpaid family worker
D19. Locus of activity
Was this work a:
[] 2 Non-household enterprise
If D18 = code 1, 2, or 4, end section D for this person.
D20. Monthly income
What was your average monthly income during the past year, including wages and salaries and other income both in money and in kind?
Write in amount in thousands of rupiah: Rp. _ _ _
E. Marriage and fertility
Ask of all ever-married women. Ask questions person by person.
[Questions E1-E11]
E1. Is this (was your previous) marriage also your first marriage?
[] T No
If E1 = code "Y", go to E3a.
E2. How many times have you been married?
[Question E2 was asked of women who have been married more than once, per question E1.]
Write in number of times married, then skip to question E3b: _
E3. Date of first marriage
E3a. In what month and year were you and your husband married?
Month:
Western_ _
Islam/Java/____
Other ____
Year:
Western_ _
Islam/Java/____
Other ____
E3b. In what month and year were you and your first husband married?
Fill in month and year of marriage in the Western or Islamic/Javanese calendars or other ____.
Month:
Western_ _
Islam/Java/____
Other ____
Year:
Western_ _
Islam/Java/____
Other ____
E4. Age at first marriage
How old were you at the time of this marriage?
E5. Total children
Now, we want to ask about the children you have given birth to. What is the total number of children you had who were born alive?
_ _
[Questions E6-E11 were asked of women who have ever married and who have ever had a live birth, as per question E1.]
E6. Children living at home.
What is the total number of children you had who were born alive and are living here with you now?
_ _
E7. Children living away from home.
What is the total number of children you had who were born alive and are living away from home?
_ _
E8. Children who have died.
What is the total number of children you had who were born alive and have since died, including any babies who lived even for only a few minutes?
_ _
Check that E6+E7+E8 = E5. If not, correct where necessary.
E9. Date of last live birth
In what month and year was your last child born?
Month:
Western_ _
Islam/Java/____
Other ____
Year:
Western_ _
Islam/Java/____
Other ____
E10. Sex of baby
Was your last baby male or female?
[] P Female
E11. Status of baby
Is this baby still living or has he/she already died?
[] 2 Already dead
For currently married women (A5=code 2 or 5) who are 50 years of age or under.
[Questions E12-E19.]
E12. Additional child
Do you still want an additional child?
[] T No
E13. Ever heard of family planning
Now we want to find out about something else. Perhaps you have heard that there are ways a woman can keep from becoming pregnant?
[] T No
If "No", stop section E for this person.
E14-E15. Knowledge of method of family planning
E14. Do you know of any specific methods that a woman can use to prevent pregnancy?
[] Y Yes
[] T No
If "No", stop section E for this person.
[Questions E15-E16 was asked of women age 50 or younger who are currently married and know of specific family planning methods, per question E14.]
E15. What methods do you know? (probe) Any others?
Circle code numbers of all methods known. To interviewer: Do not read methods aloud to the respondent.
[] 1 Pill
[] 2 I. U. D.
[] 3 Condom
[] 4 Withdrawal
[] 5 Sterilization (female)
[] 6 Rhythm
[] 7 Abstinence
[] 8 Sterilization (male)
[] 9 Other (jamu, massage, douche, etc.)
E16-E17. Ever use methods of family planning
E16. Have you ever used any of these methods of family planning?
[] Y Yes
[] T No
If "No", stop section E for this person.
[Questions E17-E18 were asked of women age 50 or younger who are currently married and have used family planning methods, as per question E16.]
E17. What methods have you used?
Circle code numbers of all methods ever used.
[] 1 Pill
[] 2 I. U. D.
[] 3 Condom
[] 4 Withdrawal
[] 5 Sterilization (female)
[] 6 Rhythm
[] 7 Abstinence
[] 8 Sterilization (male)
[] 9 Other (jamu, massage, douche, etc.)
E18-E19. Current use of methods of family planning
E18. Are you currently using a method of preventing pregnancy?
[] Y Yes
[] T No
If "No" stop section E for this person.
E19. What methods are you currently using?
[Question E19 was asked of women age 50 or younger who are currently married and currently use family planning methods.]
Circle code number of methods being currently used.
[] 1 Pill
[] 2 I. U. D.
[] 3 Condom
[] 4 Withdrawal
[] 5 Sterilization (female)
[] 6 Rhythm
[] 7 Abstinence
[] 8 Sterilization (male)
[] 9 Other (jamu, massage, douche, etc.)
If the person answering sections D or E is not the person concerned, enter the name and relationship to the head of household of that person below.
Name: ____
Relationship to head of household: ____
If the person answering sections A, B, or C is not the head of household, enter the name and relationship to the head of household of that person below.
Name: ____
Relationship to head of household: ____