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Republic of Indonesia
Central Bureau of Statistics
1985 Inter Census Population Survey

Household member characteristics
Confidential
I. Identification
Q.1. Province ____
Q.2. Regency/municipality _____
Q.3. District ____
Q.4. Village ____
Q.5. Area ____

1 Urban
2 Rural

Q.6. Enumeration area number ____
Q.7. Census block number ____
Q.8. Sample code number ____
Q.9. Sample serial number (RBS) ____
Q.10. Selected household serial number (RBS) ____

II. Recapitulation
Q.1. Number of household members ____
Q.2. Number of household members age 5 or older ____
Q.3. Number of household members age 10 or older ____
Q.4. Number of births (Code 1 at Q.9 and Q.20 Block X) _____
Q.5. Number of infant mortalities (Code 2 at Q.11 and Q.22 Block X) ____
Q.6. Total number of mortalities (from block XII B) _____

III. Enumerator's characteristics
Q.1. Enumerator name ____
Q.2. Date of enumeration ____
Q.3. Signature of enumerator ____
Q.4. Name of supervisor ____
Q.5. Date of supervision ____
Q.6. Signature of supervisor ____
Q.7. Name of informant ____

IV. Household members listing

After completing enumeration of all household members, ask once again whether names were forgotten such as new born babies, household members who are away for a while, or maids who lives in the same house. If there is, put into the listing.

Q.1 No.____
Q.2 Name of household member_____
Q.3 Relation to the head of household

_____

Q.4 Sex

1 Male
2 Female

Q.5 Age (years) _____
Q.6 Marital status

1 Single
2 Married
3 Divorced
4 Widowed

Q.7 Check mark

[Put a] check mark for married woman, divorced or widowed

[Province codes for questions 7 and 10 in block VII.A. and question 1 in code VII.B.1 are not presented here]

V. Household characteristics
Questioning to household head

Q.1. Is the income of this household from:

1 Non-agriculture (go to Q.4)
2 Agriculture sector
3 Mixture, agriculture as the main source
4 Mixture, non-agriculture as the main source

Q.2. Does this household own farmland?

1 Yes
2 No

Q.3. How much farm land area [does the household] have?

____ ha

Q.4. How much are [the household's] average expenses in a month?

____ Rp (in thousands)

VI. Building construction
Q.1. Type of physical structure

1. Single
1. Multi-story
2. Single story

2. Duplex
1. Multi-story
2. Single story

3. Multiplex
1. Multi-story
2. Single story

Q.2. Number of census buildings in this building

____ census buildings

Q.3. Number of households in this census building

____ households

Q.4. House ownership status

1 Self-owned
2 Lease (skip to Q.6)
3 Rent (skip to Q.6)
4 Rent-purchase (skip to Q.6)
5 Official (skip to Q.6)
6 Other (skip to Q.6)

Q.5 Land ownership status

1 Property right
2 Right to build
3 Right to use
4 Other

Q.6 Main material of roof

1 Concrete
2 Wood
3 Asbestos/corrugated zinc
4 Tile
5 Palm fiber
6 Leaves
7 Other

Q.7 Main material of wall

1 Brick/masonry
2 Wood
3 Bamboo
4 Other

Q.8 Main material of floor

1 Floor tile
2 Cement/concrete
3 Wood
4 Bamboo
5 Earth
6 Other

Q.9 Floor area size

____ [square meters]

Q.10 Lot size

_____ [square meters]

Q.11 Lighting used

1 Electric
2 Pump lamp
3 Kerosene
4 Other

Q.12 Fuel used for cooking

1 Electric
2 Gas
3 Kerosene
4 Wood
5 Charcoal
6 Other

Q.13 Source of drinking water

1 Piped water
2 Pump
3 Well
4 Spring
5 River
6 Rain
7 Other

Q.14 If used pump or well, distance to closest sewage disposal

[Question 14 was asked of those who use a pump or well for drinking water, per question 13.]

____ [meters]

Q.15 Source of water for bathing/washing

1 Piped water
2 Pump
3 Well
4 Spring
5 River
6 Rain
7 Other

Q.16 Bathing facilities

1 Private
2 Shared bathroom
3 Public bathroom
4 Other

Q.17 Place of toilet

1 Private toilet with septic tank
2 Private toilet without septic tank
3 Shared/public/other toilets

Q.18 Does this household possess:

1 Cupboard/buffet
2 Stove
4 Bicycle
8 Radio/cassette player
16 Television
00 Not possessed

VII. General characteristics of household members
VII. A. All ages
[Questions 1-13 were asked of persons of all ages]

Name____

Serial number of household member ____

Q.1 Relation to the head of household

1 Head of household
2 Husband/wife
3 Children
4 Son/daughter in law
5 Grandchild
6 Parent/parent in-law
7 Other relative
8 Housemaid
9 Other

Q.2 Sex

1 Male
2 Female

Q.3 Age

____ years old

Q.4 Marriage status

1 Single
2 Married
3 Divorced
4 Widowed

Q.5 Religion

1 Muslim
2 Protestant/other Christian
3 Catholic
4 Hindu
5 Buddhist
6 Other religion

Q.6 Citizenship

1 Indonesian citizen
2 People's Republic of China (PRC), Taiwan, and stateless China citizen
3 Other foreign citizen

Q.7 Place of birth

Province ____
Regency/municipality ____

Q.8 Ever lived in another regency/municipality

1 Yes
2 No

Q.9 Duration of time living in the current regency/municipality

____years

Q.10 Previous residence

Province ____
Regency/municipality ____

Q.11 Reason moved

1 Transmigration
2 Employment
3 Education
4 Other

Q.12 Living with biological mother

1 Yes
2 No (go to block VII. B)

Q.13 Serial number of biological mother

____

VII. B. Persons age 5 or older
[Questions 1-6 were asked of persons age 5 or older]

Q.1 Residence in October 1980

Province ____
Regency/municipality ____

Q.2 School attendance status

[] 1 No/not yet in school (go to Q.5)
[] 2 Attending school
[] 3 No longer in school

Q.3 Type of highest education ever or being attended

[] 1 Primary school
[] 2 Junior high
[] 3 Vocational junior high school
[] 4 High school
[] 5 Vocational high school
[] 6 Diploma I/II
[] 7 Academy/Diploma III
[] 8 University

Q.4 Highest level/class ever or being attended

[] 1 Class 1
[] 2 Class 2
[] 3 Class 3
[] 4 Class 4
[] 5 Class 5
[] 6 Class 6
[] 7 Class 7
[] 8 Completed

Q.5 Highest education ever completed

[] 1 Never attended/not yet attended school
[] 2 Less than primary school
[] 3 Primary school
[] 4 Junior high school
[] 5 Vocational junior high school
[] 6 High school
[] 7 Vocational high school
[] 8 Diploma I/II
[] 9 Academy/diploma III
[] 0 University

Q.6 Can write and read

[] 1 Latin alphabet
[] 2 Other alphabet
[] 3 Cannot [read and write]

VII.C. Person age 10 or older
[Questions 1-5 were asked of persons age 10 or older]

Q.1 What kind of activity [was] done during the previous week?

[] 1 Working (go to block VIII)
[] 2 School
[] 3 Homemaking
[] 4 Unable to work
[] 5 Other

Q.2 Did [the respondent] work at least 1 hour during the previous week?

[] 1 Yes (go to block VIII)
[] 2 No

Q.3 Does [the respondent] have a permanent job but is temporarily not working during the previous week?

[] 1 Yes (go to block VIII)
[] 2 No

Q.4 Has [the respondent] ever worked before?

[] 1 Yes
[] 2 No

Q.5 Did [the respondent] look for work during the previous week?

[] 1 Yes (go to Q.11, section VIII)
[] 2 No (go to Q.14, section VIII)

VIII. Work force
(Persons age 10 or older)
[Questions 1-17 were asked of persons age 10 or older]

Q.1 Number of hours worked in the previous week

Day 1 ____ hours
Day 2 ____ hours
Day 3 ____ hours
Day 4 ____ hours
Day 5 ____ hours
Day 6 ____ hours
Day 7 ____ hours
Total ____ hours

Q.2 Type of main work

____

Q.3 Main work status

[] 1 Self-employed
[] 2 Self-employed assisted by family members/temporary workers
[] 3 Employer with permanent workers
[] 4 Worker/employee
[] 5 Family worker

Q.4 Total number of hours worked in main occupation during the previous week

____ hours

Q.5 Describe the type of activity/field of work of the working place/company/office of the [respondent's] main occupation

____

Q.6 Does [the respondent] have any additional work?

[] 1 Yes
[] 2 No (go to Q.10)

Q.7 Number of hours worked in additional work during previous week

____ hours

Q.8 Describe the type of activity/field of work of the working place/company/office of the additional work

____

Q.9 Besides the two kinds of work, does [the respondent] still have other work?

[] 1 Yes
[] 2 No

Q.10 Did [the respondent] look for work during the previous week?

[] 1 Yes
[] 2 No (go to Q.14)

Q.11 How long [has the respondent] been looking for work?

____months

Q.12 Kind of work looked for:

[] 1 Full time
[] 2 Part-time

Q.13 What kinds of effort has [the respondent] been putting into looking for work?

[] 1 Contacted relatives/acquaintances
[] 2 Applied from advertisements
[] 4 Contacted some companies/offices (go to Q. 16)
[] 8 Registered at Ministry of Manpower
[] 16 Other

Q.14 Reason for not looking for work last week

[] 1 Not needed
[] 2 Waiting for outcome of job application
[] 3 Schooling
[] 4 Housekeeping
[] 5 Unable to work
[] 6 Other

Q.15 [Is the respondent] willing to accept any type of work?

[] 1 Yes
[] 2 No

Q.16 Did [the respondent] work during the previous year?

[] 1 Yes
[] 2 No (end of this block)

Q.17 Describe the type of activity/field of work of the working place/company

____

IX. Ever married women
[Questions 1-5 were asked of married women.]

Name____
No. household member ____
Q.1 Number of marriages

____times

Q.2 Year and month of first marriage

Month____
Year 19_ _

Q.3 Age when first married

____years old

Q.4 Number of total children born alive of married women:

a. Still alive
____M
____F
____M+F
a.1 Live in this household
____M
____F
____M+F
a.2 Live outside of this household
____M
____F
____M+F
Total
____M
____F
____M+F
b. Passed away
____M
____F
____M+T
c. Born alive (a+b)
____M
____F
____M+F

Q.5 Age when first gave birth

____years old

X. For a woman [who] ever gave birth younger than 55
[Questions 1-23 were asked of women who ever gave birth and younger than 55 years.]

Q.1 Name of the last child ____

(If twins, write down [both] children's names)

Q.2 After the birth of that child, has [the respondent] ever been pregnant again?

[] 1 No (go to Q.5)
[] 2 Yes, pregnant (go to Q.5)
[] 3 Yes, miscarried (go to Q.5)
[] 4 Yes, born alive (go to Q.5)
[] 5 Yes, stillborn

Q.3 Age of pregnancy when gave birth

[] 1 Fewer than 7 months (go to Q.5)
[] 2 7 months or more

Q.4 Did the baby show signs of life? (such as breathing, crying)

[] 1 Yes
[] 2 No

Q.5 Was the last child born?

[] 1 Single
[] 2 Twins

Q.6 Name of that child

____

(If twins, write down [both] names)

Q.7 Sex

[] 1 Male
[] 2 Female

Q.8 When was the last child born?

Month____
Year ____

Q.13. Has [the respondent] ever been pregnant before the last pregnancy?

([Mention] the name of the child mentioned in Q.6)

[] 1 No (go to block XI)
[] 2 Yes, miscarried (go to block XI)
[] 3 Yes, born alive (go to Q.16)
[] 4 Yes, still born

Q.14 Age of pregnancy when gave birth?

[] 1 Fewer than 7 months (go to block XI)
[] 2 7 months or more

Q.15 Did the baby show signs of life? (such as breathing, crying)

[] 1 Yes
[] 2 No (go to block XI)

Q.16 Was the child born?

[] 1 Single
[] 2 Twins

Q.17 Name of that child

____

(If twins, write down both names)

Q.18 Sex

[] 1 Male
[] 2 Female

Q.19 When was the child born?

Month____
Year____

Q.20 [Is missing]

Q.21 Does the child live in this household?

[] 1 Yes, no. household member ____; name____ (go to section XI)
[] 2. No, 00

Q.22 [Is missing]

Q.23 Age when died

[] 1 Fewer than 30 days (in days)
[] 2 30 days or more (in months)

XI. For a woman younger than 50 years and married
[Questions 1-3 were asked of women younger than 50 years and married]

Q.1 Type of contraceptive currently used:

[] 1 Tubectomy
[] 2 Vasectomy
[] 3 I.U.D.
[] 4 Injection
[] 5 Oral pill
[] 6 Condom
[] 7 Other
[] 8 Not used

Q.2 Has [the respondent] ever used contraceptive?

[] 1 Yes
[] 2 No

Q.3 Source of contraceptive/service:

[] 1 FP clinic/puskesmas/hospital/PKBRS
[] 2 FP field workers/other field workers
[] 3 FP post/FP group/Banjarvillage FP field worker assistance
[] 4 FP mobile team
[] 5 Safari (special event)
[] 6 Pharmacy
[] 7 Private doctor/midwife
[] 8 Other

XII. Health information

(Ask to household head)

XII.A. Born after June 30, 1984
Q.1 Name____
Household member's number ____

Q.2 Is the child still alive?

[] 1 Yes
[] 2 No

Q.3 Duration of breast-feeding

____months

Q.4 Birth attended [by:]

[] 1 Doctor
[] 2 Midwife/paramedics
[] 3 Traditional birth attendant
[] 4 Other

Q.5 [Child] has [received] vaccination/immunization

[] 1 Yes
[] 2 No (go to Q.7)

Q.6 Type of vaccination/immunization

[] 1 BCG
[] 2 DPT
[] 3 Polio
[] 4 Measles

Q.7 Reason not to have vaccination/immunization

[] 1 Too young
[] 2 Don't know about vaccination
[] 3 Afraid of fever
[] 4 Too far from vaccination's place
[] 5 Too expensive
[] 6 Don't know
[] 7 Other

XII. B. Death after June 30, 1984
Q.1 Name____

Q.2 Sex

[] 1 Male
[] 2 Female

Q.3 Relation to the head of household

____

Q.4 Month and year of death

Month____
Year____

Q.5 Age when died____

In months (if younger than one year)
In years (if one year or older)

Q.6 Causes of death

[] 1 High fever
[] 2 Diarrhea
[] 3 Convulsions
[] 4 Accident
[] 5 Delivery/giving birth
[] 6 Other

[Instructions on how to fill the form are not included here]