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Republic of Indonesia
2000 Population Census

SP2000-L2

Filled by enumerator

Province _ _
Regency/municipality _ _
Sub-district _ _ _
Village _ _ _
Census block no. _ _ _ _
PB no. _ _ _
Household serial no. _ _ _

HH type

[] Ordinary
[] Special

Characteristics of Individual Household Members
Included: 1. Baby; 2. Guests or visitors who have been staying for the past six months or fewer than 6 months but intended to stay; 3. Servants who staying in this household.

Not included: 1. Persons who have been away for the past six months, or fewer than 6 months and intended to move away; 2. Servants who are not staying in this household.

Total number of household members ____
Description

1. Name: ____
Serial number: ____

2. Relationship to head of the household

[] 1 Head
[] 2 Spouse
[] 3 Children
[] 4 Other

3. Sex

[] 1 Male
[] 2 Female

4. Place of birth

Province: ____
Regency/city: ____

5. Month and year of birth and age

a. Month: ____
Year: ____
b. How old are you? (in years): ____

6. Marital status

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

7. Religion

[] 1 Muslim
[] 2 Catholic
[] 3 Protestant
[] 4 Hindu
[] 5 Buddhist
[] 6 Other

8. Citizenship/ethnicity

[] 1 Indonesian
[] 2 Other

Specify ethnic group/citizenship: _ _ _ _

Household members age 5 or older
[Questions 9-13 were asked of persons age 5 or older]

9. Place of residence 5 years ago

Province: ____
Regency/city: ____

10. Highest education completed

[] 1 No schooling
[] 2 Primary school
[] 3 Junior high school
[] 4 Senior high school
[] 5 College [1-2 year. diploma]
[] 6 Academy [3 year diploma]
[] 7 Undergraduate/graduate [diploma in 4 or more years]

11. What kind of activities during the previous week?

[] 1 Employed
[] 2 Looking for work
[] 4 School
[] 8 Other

[Questions 12 to 13: for persons age 5 or older who are employed during the previous week.]

12. If Q11 code 1, type of main industry

[] 1 Food crops
[] 2 Plantation
[] 3 Fishery
[] 4 Animal husbandry
[] 5 Other agriculture
[] 6 Manufacturing
[] 7 Trade
[] 8 Services
[] 9 Transportation
[] 0 Others

13. Employment status

[] 1 Self-employed
[] 2 Self-employed/[employer] assisted by temporary employees
[] 3 Employer
[] 4 Employee
[] 5 Unpaid worker

Ever married women age 10 or older
[Questions 14-15 were asked of ever married women age 10 or older]

14. Total number of children ever born ____

15. Total number of children still alive ____