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Republic of Indonesia
Central Bureau of Statistics
1995 Intercensal Population Survey
Sample Census

Confidential

I. Location identification
101. Province ____ _ _
102. Regency/municipality (cross out category not used) ____ _ _
103. Sub-regency/sub-district _____ _ _
104. Village ____ _ _ _
105. Area

[] 1 Urban
[] 2 Rural

106. Enumeration area number ____
107. Sample code number _ _ _ _ _
108. Number of segment group/number of segment

No. segment group____
No. segment____

109. Physical building number/census building number

PBN____
CBN____
110. Sample serial number _ _
111. Selected household number ____
112. Number of household members _ _
113. Number of migrant household five years ago _ _
114. Number of ever married women 10-54 years _

115. Number of page that Q514 has been filled

[] 4
[] 6
[] 8
[] 10
[] 12
[] 14
[] 16
[] 18
[] 20
[] 22
[] 24
II. Enumeration particulars

201. Name

Enumerator ____
Supervisor ____

202. ID number

Enumerator _ _ _ _ _ _ _ _ _
Supervisor _ _ _ _ _ _ _ _ _
203. Date of enumeration or supervision

Enumerator ____ to ____
Supervisor ____ to ____

204. Signature

Enumerator ____
Supervisor ____
III. List of household numbers

No._ _

301. Name____

(Please give me the names of the persons who usually live in [the respondent's] household, starting with the head of the household.)

302. What is the relationship of [the respondent] to the head of the household?

[] 1 Head
[] 2 Spouse
[] 3 Child
[] 4 Child in-law
[] 5 Grandchild
[] 6 Parent
[] 7 Parent in-law
[] 8 Brother or sister
[] 9 Other relative
[] 10 Adopted/foster child
[] 11 Not related
[] 12 Servant

303. Is [the respondent] male or female?

[] 1 Male
[] 2 Female

304. How old is [the respondent]?

_ _ years

If members of the household are younger than 15
[Questions 305-308.]

305. Is [the respondent's] natural mother alive?

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

306. If alive, does [the respondent's] natural mother live in this household?

[Question 306 asked of persons younger than 15 whose mother is alive, as per questions 304 and 305.]

If yes, record mother's line number (This question refers to relationship between parent and son or daughter. Code "00" if parent is not a member of the household.)

_ _

307. Is [the respondent's] natural father alive?

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

308. If alive does [the respondent's] natural father live in this household?

[Question 306 asked of persons younger than 15 whose father is alive, as per questions 304 and 305.]

If yes, record father's line number (This question refers to relationship between parent and son or daughter. Code "00" if parent is not a member of the household.)

_ _

309. Is [respondent] ever married?

[Question 309 asked of] women age 10-54 years

[] 1 Yes
[] 2 No

Just to make sure that [the enumerator] has completed a listing

1) Are there any other persons such as small children or infants that we have not listed?

[] Yes (Enter each in table)
[] No

2) Are there any other people who may not be members of [respondent's] family, like servants, friends, lodgers, but who usually live here?

[] Yes (Enter each in table)
[] No

3) Are there any other guests or visitors who have been temporarily staying with you for the past six months or more?

[] Yes (Enter each in table)
[] No

4) Are there any persons who usually live here who have been away for fewer than six months?

[] Yes (Enter each in table)
[] No

5) Are there any persons we have listed who have been away for the past six months?

[] Yes (Enter each in table)
[] No
IV. Household information

401. The means of livelihood for this household during the last year

[] 1 Non-agriculture only
[] 2 Agriculture only
[] 3 Mixture: agriculture the primary means
[] 4 Mixture: non-agriculture the primary means

402. This household owns agricultural land

[] 1 Yes
[] 2 No (go to Q404)

403. The area of agricultural land

[Question 403 was asked of households that own agricultural land, as per question 402.]

_ _. _ _ha

404. Type of physical structure

[] 1 Independent structure with single living quarters
[] 1 Multi storied
[] 2 Single storied
[] 2 Independent structure with two living quarters
[] 1 Multi storied
[] 2 Single storied
[] 3 Independent structure with more than two living quarters
[] 1 Multi storied
[] 2 Single storied

405. Number of census buildings in this physical building

Census buildings _ _

406. Number of households in this census building

Household(s) _ _

407. Ownership status of dwelling unit

[] 1 Self-owned
[] 2 Installments
[] 3 Contract (go to Q409)
[] 4 Rent (monthly basis) (go to Q409)
[] 5 Official (go to Q409)
[] 6 Other, specify ___ (go to Q409)

408. Ownership status of the land

[Question 408 was asked of households that self-own or are paying installments for the dwelling unit, per question 407.]

[] 1 Self-owned
[] 2 Right to build
[] 3 Right to use
[] 6 Other, specify ____

409. Primary construction material of roof

[] 1 Concrete
[] 2 Wood
[] 3 Tile
[] 4 Asbestos
[] 5 Corrugated zinc
[] 6 Sugar palm fiber
[] 7 Leaves
[] 96 Other, specify ____

410. Primary construction material of outer wall

[] 1 Brick
[] 2 Wood
[] 3 Bamboo
[] 6 Other, specify ____

411. Primary construction material of floor

[] 1 Ceramic/marble/granite
[] 2 Tile
[] 3 Cement/brick
[] 4 Wood
[] 5 Bamboo
[] 6 Earth
[] 96 Other, specify ____

412. Floor area

_ _ _ square meters

413. Area of building and yard

_ _ _ _ square meters

414. Type of lighting

[] 1 Electric
[] 2 Gas
[] 3 Pumped lamp
[] 4 Kerosene lamp
[] 6 Other, specify ____

415. Type of cooking fuel

[] 1 Electric
[] 2 Gas
[] 3 Kerosene
[] 4 Wood
[] 5 Charcoal
[] 6 Other, specify ____

416. Source of drinking water

[] 1 Piped water (go to Q418)
[] 2 Pump
[] 3 Well
[] 4 Spring (go to Q418)
[] 5 River (go to Q418)
[] 6 Rainwater (go to Q418)
[] 96 Other, specify ____ (go to Q418)

417. How far is the distance between the well and the nearest cesspool?

[Question 417 was asked of households whose source of drinking water is pump or well, per question 416.]

_ _ meters

418. Source of water for bathing/washing

[] 1 Piped water
[] 2 Pump
[] 3 Well
[] 4 Spring
[] 5 River
[] 6 Rainwater
[] 96 Other, specify ____

419. Bathing facility

[] 1 Private
[] 2 Shared
[] 3 Public
[] 6 Other, specify ____

420. Toilet facility

[] 1 Private, with septic tank
[] 2 Private, without septic tank
[] 3 Shared
[] 4 Public
[] 5 Dry latrine
[] 6 Bushes/forest/yard
[] 7 Pond
[] 8 River/stream
[] 96 Other, specify ____

421. Does this household own/has access to:

a. Sideboard/buffet
[] 1 Yes
[] 2 No
b. Stove
[] 1 Yes
[] 2 No
c. Bicycle/boat
[] 1 Yes
[] 2 No
d. Radio/cassette recorder
[] 1 Yes
[] 2 No
e. TV/video/laser disc
[] 1 Yes
[] 2 No
f. Motorcycle/speed boat
[] 1 Yes
[] 2 No
g. Car/ship
[] 1 Yes
[] 2 No

V. Characteristics of individual household members

501. Name ____

No. _ _

502. Relationship to head of household

[] 1 Head
[] 2 Spouse
[] 3 Child
[] 4 Child in-law
[] 5 Grandchild
[] 6 Parent
[] 7 Parent in-law
[] 8 Brother/sister
[] 9 Other relative
[] 10 Adopted/foster child
[] 11 Not related
[] 12 Servant

503. Sex

[] 1 Male
[] 2 Female
504. Date of birth

Date _ _
Month _ _
Year _ _

505. Age

_ _ years
506. Marital status

[] 1 Single
[] 2 Married
[] 3 Divorced
[] 4 Widowed

507. Religion

[] 1 Moslem
[] 2 Catholic
[] 3 Protestant/other Christian
[] 4 Hindu
[] 5 Buddhist
[] 6 Other, specify ____

508. Citizenship

[] 1 Indonesian
[] 2 Chinese (PRC, Taiwan, or stateless) (go to Q509a)
[] 3 Other foreigner (go to Q509a)

509. Place of birth

Province _ _
Regency/municipality _ _

509a. Ever lived in other regency/municipality?

[] 1 Yes
[] 2 No (go to Q511)

510. Place of previous residence

[Question 510 was asked of persons who have ever lived in another regency/municipality, as per question 509a.]

Province _ _
Regency/municipality _ _

511. Duration of residence in present village

_ _ years

512. See Q505

Age 4 or younger (go to Q501 then next respondent)
Age 5 or older (go to Q513)

[Questions 513- 525 were asked of persons age 5 or older]

513. See Q511 [Duration of residence in present village]

Age 5 or older (go to Q 516)
Age 4 or younger (go to Q 514)
[Questions 514-515 was asked of persons age 5 or older who have lived in present village for fewer than five years, per question 511.]

514. Place of residence five years ago (October 1990)

Province _ _
Regency/municipality _ _
District _ _ _
Village _ _ _
[] 1 Urban
[] 2 Rural

515. Main reason moved from place of residence five years ago

[] 1 Occupation
[] 2 Looking for work
[] 3 Education
[] 4 Marital status
[] 5 Following spouse/parent/children
[] 6 Following brother/sister/other relative
[] 7 Housing
[] 96 Other, specify ____

516. School attendance

[] 1 Has never attended school (go to Q521)
[] 2 Attending school
[] 3 Does not attend school anymore

[Questions 517-519 were asked of persons age 5 or older who have ever attended school, as per question 516.]

517. Highest level of education attended/attending

[] 1 Primary school
[] 2 General junior high school
[] 3 General senior high school
[] 4 Vocational junior high school
[] 5 Vocational senior high school
[] 6 Diploma I/II
[] 7 Academy/diploma III
[] 8 University/diploma IV

518. Highest grade attended/attending

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

519. Highest level of education completed

[] 1 Did not complete primary school (go to Q521)
[] 2 Primary school (go to Q522)
[] 3 General junior high school (go to Q522)
[] 4 General senior high school (go to Q522)
[] 5 Vocational junior high school
[] 6 Vocational senior high school
[] 7 Diploma I/II
[] 8 Academy/diploma III
[] 9 University/diploma IV

520. Field of study

[Question 520 was asked of persons age 5 or older who have ever attended school and completed vocational school, diploma, academy or university, as per questions 516 and 519.]

____ (go to Q522)

521. Able to read and write

[Question 521 was asked of persons age 5 or older who have never attended school or have not completed primary school, as per questions 516 and 520.]

[] 1 Latin alphabet
[] 2 Other alphabet
[] 3 Illiterate

522. Mother tongue

[] 1 Indonesian
[] 2 Local language, specify ____
[] 3 Foreign language

523. Language used at home

[] 1 Indonesian
[] 2 Local language, specify ____
[] 3 Foreign language

524. Able to speak Indonesian

[Question 524 was asked of persons age 5 or older who do not use the Indonesian language at home, as per question 523.]

[] 1 Yes
[] 2 No

525. See Q505

Age 9 or younger (go to Q501 next respondent)
Age 10 or older (go to block VI)
VI. Economic activity of persons age 10 or older
[Questions 601 to 615]

601. Primary activity in the previous week

[] 1 Working (go to Q604)
[] 2 Attending school
[] 3 Housekeeping
[] 6 Other, specify ____

602. In addition to [selections in Q601] 2, 3 and 6, also worked for at least one hour during the previous week

[Question 602 was asked of persons age 10 or older whose primary activity in the previous week was not work, as per question 601.]

[] 1 Yes (go to Q604)
[] 2 No

603. Hold a job but temporarily absent

[Question 603 was asked of persons age 10 or older who did not work during the previous week, as per questions 601 and 602.]

[] 1 Yes
[] 2 No (go to Q612)

[Questions 604-608 were asked of persons age 10 or older who are employed, worked at least one hour or held a job but were temporarily absent during the previous week, as per questions 601, 602 and 603.]

604. Number of hours worked every day in the previous week

Day 1_ _
Day 2_ _
Day 3_ _
Day 4_ _
Day 5_ _
Day 6_ _
Day 7_ _
Total _ _
Number of days _
Number of hours _ _

605. Number of hours worked in primary activity in the previous week

_ _ hours

606. Occupation in the primary activity in the previous week

____

607. Type of industry in primary activity during the previous week

____

608. Employment status in primary activity during the previous week

[] 1 Self-employed (go to Q610)
[] 2 Self-employed assisted by family member/temporary help (go to Q610)
[] 3 Employer (go to Q610)
[] 4 Employee
[] 5 Unpaid worker (go to Q610)

609. Average salary/wage during previous month from primary activity

[Question 609 was asked of persons age 10 or older who were employees during the previous week, as per question 608.]

1 Money: Rp _ _ _ _ _ _ _ _
2 Goods: Rp _ _ _ _ _ _ _ _

610. Did you have an additional job in the previous week?

[Question 610 was asked of persons age 10 or older who are employed, worked at least one hour or held a job but were temporarily absent during the previous week, as per questions 601, 602 and 603.]

[] 1 Yes
[] 2 No (go to Q612)

611. Type of industry of additional job during previous week

[Question 611 was asked of persons age 10 or older who had an additional job in the previous week, as per question 610.]

[] 1 Agriculture
[] 2 Mining and quarrying
[] 3 Manufacturing
[] 4 Electricity, gas, and water
[] 5 Construction
[] 6 Trade
[] 7 Transportation and communication
[] 8 Finance
[] 9 Services
[] 96 Other, specify ____

612. Did you look for work?

[] 1 Yes (go to Q614)
[] 2 No

613. Primary reason for not seeking work

[Question 613(a) was asked of persons age 10 or older who did not look for work, as per question 612.]

[] 1 Did not need work
[] 2 Gave up trying
[] 3 Attending school
[] 4 Housekeeping
[] 5 Incapable of work
[] 6 Other, specify ____

613a. Do you want to receive a job?

[] 1 Yes
[] 2 No

614. Did you work during the previous year?

[] 1 Yes
[] 2 No (continue to Q501 for next respondent)

615. Type of industry during the previous year

[Question 615 was asked of persons age 10 or older who worked during the previous year, as per question 614.]

____ (continue to Q501 for next respondent)

VII. Ever married women age 10-54
[Questions 701-716]

701. Name____

No. _ _
702. Number of marriages

_ _ times

703. Month and year of first marriage

Month _ _
Year _ _

704. How old was [the respondent] when you first married?

_ _ years

705. How old was [the respondent's] last husband when you first married?

_ _ years

706. Have you ever given birth?

1 Yes
2 No (go to Q701 for next ever married woman)

[Question 707 was asked of ever married women age 10-54 who ever gave birth, as per question 706.]

707. How many sons and how many daughters live with [the respondent]?

Sons _ _
Daughters _ _

708. How many sons and how many daughters are alive but do not live with [the respondent]?

Sons _ _
Daughters_ _

709. How many boys and girls have died?

Sons_ _
Daughters _ _

710. Number of ever born children

_ _

711. What name was given to [respondent's] (first, then next) baby?

[Question 711 was asked of ever married women age 10-54 who ever gave birth, as per question 706.]

____

712. Is [the respondent's baby] a boy or a girl?

[Question 712 was asked of ever married women age 10-54 who ever gave birth, as per question 706.]

[] 1 Boy
[] 2 Girl

713. In what month and year was [the respondent's baby] born

[Question 713 was asked of ever married women age 10-54 who ever gave birth, as per question 706.]

Month _ _
Year _ _

714. Is [the respondent's baby] still alive?

[Question 714 was asked of ever married women age 10-54 who ever gave birth, as per question 706.]

[] 1 Yes
[] 2 No (go to Q716)

715. How old was [the respondent's baby]?

_ _

716. How old was [the respondent's baby] when he/she died?

[Question 716 was asked of ever married women age 10-54 whose child is no longer alive, as per question 714.]

1 _ _ months
2 _ _years

Continue to Q701 next ever married women