Republic of Indonesia
BPS Statistics of Indonesia
2005 Intercensal Population Survey
Sample Survey
I. Location identification
101. Province _ _
102. Regency/municipality _ _
103. Sub-district _ _ _
104. Village _ _ _
105. Village classification _
[] 2 Rural
106.
____ B. Sub-census block number
107. Sample code number _ _ _ _
108. Physical building number/census building number
____ CBN
109. Selected household number _ _
201. ____ Name of the head of household
202. _ _ Number of household members
203. _ _ Number of household members age 5 or older
204. _ _ Number of household members age 10 or older
205. _ _ Number of household members age 60 or older
206. _ _ Number of ever married women age 10 or older
207. _ _ Number of dead people
301. ID number of enumerator _ _ _ _ _
302. Type of enumerator _
[] 2 Subdistrict census coordinator
[] 3 Temporary personnel
303. Enumerator statement: I take seriously the task of filling out this questionnaire pursuant to the interview with the respondent of household members
____ Signature name
304. ID number of supervisor _ _ _ _ _
305. Type of supervisor _
[] 2 Subdistrict census coordinator
[] 3 Temporary personnel
306. Supervisor statement: This questionnaire is really in my observation and I have checked it according to the guidance book
____ Signature name
IV.A. List of household members
401. Who usually lives and eats in this household [including all] adults, children, or babies?
402. What is the relationship of [the respondent] to the head of the household?
[] 2 Spouse
[] 3 Child
[] 4 Son/daughter in law
[] 5 Grandchild
[] 6 Parent/parent in law
[] 7 Other relative
[] 8 Housemaid
[] 9 Other
403. Is [the respondent] male or female?
[] 2 Female
404. How old is [the respondent]? _ _
405. What is [the respondent's] marital status?
[] 2 Married
[] 3 Divorced
[] 4 Widowed
406. Does [the respondent] have a birth certificate from civil registration?
[Question 406 was asked of persons age 0 to 4.]
[] 2 No
407. Does [the respondent] have an identity card?
[Question 407 was asked of persons age 17 or older or who have ever been married]
[] 2 No
408. Was she ever married?
[Question 408 was asked of women who were age 10 or older.]
[] 2 No
Check the corresponding box to assure that [everyone was counted in the questions in section IV.A. who should have been]:
1. Are there any other persons such as children or infants who have not been listed?
[] 2 No
2. Are there any people who are not your family members such as housemaids, lodgers, or friends who usually live here?
[] 2 No
3. Are there any guests or temporary visitors staying here for six months or more who have not been listed?
[] 2 No
4. Are there any other people who usually live here but have gone away for less than six months?
[] 2 No
5. Are there any people who have been listed as a member of household who have gone away for fewer than six months but intend to move?
[] 2 No
IV.B. Occurrence of deaths since January 2002
409. What is the name of the dead person? ____
410. What year did [the deceased] die? _ _
411. Sex of [the deceased]?
[] 2 Female
412. How old was [the deceased] when [he/she] died?
413. What caused [the deceased] to die?
[] 2 Not a traffic accident
[] 3 Not an accident
414. Did the deceased die:
[Question 414 was asked of deceased women age 10 or older]
[] 2 No
[] 2 No
[] 2 No
501. Does this household have a family card from current residence?
[] 2 No
502. Does this household have a family card with other address?
[Question 502 was asked of household without a family card from the current residence, as per question 501.]
[] 2 No
503. Has a birth occurred in this household within the last year?
[] 2 No [go to Q.506]
504. Has the birth been reported to the village office?
[Question 504 was asked of households with a birth occurrence in the last year, as per question 503.]
[] 2 Yes, partly
[] 3 No [go to Q.506]
505. Has the household received a birth statement letter from the village office for the birth reported?
[Question 505 was asked of households with a birth occurrence in the last year that has been reported to the village office, as per questions 503-504.]
[] 2 Yes, partly
[] 3 No
506. Has a death occurred in this household within the last year?
[] 2 No [go to Q.509]
507. Has the death been reported to the village office?
[Question 507 was asked of households with a death in the last year, as per question 506.]
[] 2 Yes, partly
[] 3 No [go to Q.509]
508. Has the death report received a death statement letter from the village office?
[Question 508 was asked of households with a death in the last year that has been reported to the village office, as per questions 506-507.]
[] 2 Yes, partly
[] 3 No
509. In the last year have there been any members or ex-members of this household who have moved to another village?
[] 2 No [go to Q.512]
510. Has the location change been reported to the village office?
[Question 510 was asked of households with a member who moved in during the last year, as per question 509.]
[] 2 Yes, partly
[] 3 No [go to Q.512]
511. If reported, has a statement letter from the village office been received for all location changes?
[Question 511 was asked of households with a member who moved during the last year that was reported to the village office, as per questions 509-510.]
[] 2 Yes, partly [for some, but not all, moves]
[] 3 No
512. In the last year, have there been any members or ex-members of this household who have moved into this village from another village?
[] 2 No [go to Q.515]
513. Has the move-in been reported to the village office?
[Question 513 was asked of households with a member who moved in during the last year, as per question 512.]
[] 2 Yes, partly
[] 3 No [go to Q.515]
514. If reported, has a statement letter, family card, or identity card been received for all moves-ins?
[Question 514 was asked of households with a member who moved in during the last year, which was reported to the village office, per questions 512-513.]
[] 2 Yes, partly [for some, but not all, moves]
[] 3 No
515. What is the ownership of this dwelling unit?
[] 2 Contract
[] 3 Rent
[] 4 Free
[] 5 Official
[] 6 Parent/relatives-owned
[] 96 Other (specify) ____
516. Primary construction material of roof.
[] 2 Wood
[] 3 Tile
[] 4 Asbestos/zinc
[] 5 Sugar palm fiber/leaves
[] 6 Other (specify) ____
517. Primary construction material of outer wall.
[] 2 Wood
[] 3 Bamboo
[] 4 Other (specify) ____
518. Primary construction material of floor.
[] 2 Tile
[] 3 Cement/brick
[] 4 Wood
[] 5 Bamboo
[] 6 Earth
[] 96 Other
519. Floor area
520. What is the primary lighting in this dwelling unit?
[] 2 Gas
[] 3 Pump lamp
[] 4 Kerosene lamp
[] 6 Other (specify) ____
521. What is the primary cooking fuel used in this household?
[] 2 Gas
[] 3 Kerosene
[] 4 Coal
[] 5 Charcoal
[] 6 Wood
[] 96 Other (specify) ____
522. What is the primary source of drinking water for this household's members?
[] 2 Covered well
[] 3 Uncovered well
[] 4 Covered spring
[] 5 Uncovered spring [go to Q.524]
[] 6 River [go to Q.524]
[] 7 Lake/dam [go to Q.524]
[] 8 Rain water [go to Q.524]
[] 9 Bottled water [go to Q.524]
[] 96 Other (specify) ____ [go to Q.524]
523. How far is the distance between the well and the nearest cesspool?
[The questionnaire suggests that Question 523 was to be asked of those who answered "covered spring", but the census instructions and the data indicate they were not asked.]
524. Where do the household members take a bath?
[] 2 Shared bathroom
[] 3 Public bathroom
[] 6 Other (specify) ____
525. What kind of toilet facility does your household have?
[] 2 Private toilet with no septic tank
[] 3 Shared toilet
[] 4 Public toilet
[] 5 River
[] 6 Pit
[] 7 Yard/bush/forest
[] 96 Other (specify) ____
526. Do any of your household members own:
[] 2 No
[] 4 No
[] 6 No
[] 8 No
[] 1 No
[] 3 No
[] 5 No
1. Are there age questions (Q.404 and Q.603) that have not yet been filled?
[] 2 No
2. For each household members, is the age recorded for Q.404 the same as for Q.603 ?
[] 2 Done
3. Are any household members for whom [questions] Q.601 - Q.610 have not yet been filled?
[] 2 No
4. Are there any household members age 5 or older for whom Q. 611 - Q.629 have not yet been filled?
[] 2 No
5. Are there any household members age 10 or older for whom Q. 626 - Q.629 have not yet been filled?
[] 2 No
6. Are there any household members age 60 or older for whom Q. 630 - Q.639 have not yet been filled?
[] 2 No
VI. Characteristics of individual household members
VI.A. Household members of all age
[Questions 601 - 610 were asked of all household members.]
601. Name: ____
No. household member _ _
602. When were you born?
Year _ _ _ _
603. Write age at the last birthday.
How old are you now?
[] 2 Catholic
[] 3 Protestant
[] 4 Hindu
[] 5 Buddhist
[] 6 Confucian
[] 96 Other (specify) ____
605. What is your citizenship status?
[] 2 Foreigner [go to Q.606b]
606a. What is your ethnicity?
[Question 606a was asked of persons who answered "Indonesian" in question 605.]
[] 3 Java
[] 5 Nusa Tenggara
[] 6 Kalimantan
[] 7 Sulawesi
[] 8 Maluku
[] 9 Papua
[] 0 Foreign
Ethnicity code _ _ _ _
606b. What is your citizenship?
[Question 606b was asked of persons who answered "Foreigner" in question 605.]
Filled by supervisor
607. Where were you born?
Regency/municipality _ _
608. Did you ever live in other regencies/municipalities?
[] 2 No [if age is younger than 5, go to the next household member; if age is 5 or older, go to Q.616]
[Questions 609 - 615 were asked of persons who answered "Yes" in question 608.]
609. Where was your last residence before you lived in your current residence?
Regency/municipality _ _
610. How long have you lived in this current regency/municipality?
VI.B. Household members age 5 or older
[Questions 611 - 625 were asked of household members age 5 or older.]
611. Do you return to your hometown periodically?
[] 2 No [go to Q.613]
612. How often do you return to your hometown?
[Question 612 was asked of persons who answered "Yes" in question 611.]
[] 2 Once a month
[] 3 At least once in six months
[] 4 Seldom
613. [How long have you lived in this current regency/municipality?] (from Q.610)
[] 5 years or more [go to Q.616]
[Questions 614 - 615 were asked of persons age 5 or older who have lived in the current regency/municipality for "4 years or fewer", as per question 613.]
614. Where did you live five years ago (June 2000)?
Province _ _
Regency/municipality _ _
615. What was your main reason for moving from your residence five years ago?
[] 2 Looking for work
[] 3 Education
[] 4 Marital status change
[] 5 Following spouse/parent/children
[] 6 Following sibling/other relatives
[] 7 Housing
[] 8 Security
[] 96 Other (specify) ____
616. Did you ever or still attend school?
[] 2 Attending school
[] 3 Not attending school any more
[Questions 617 - 619 were asked of persons age 5 or older who are "Attending school" or "Not attending school any more", as per question 616.]
617. What is your completed highest level of education; or, what education level do you currently attend?
[] 2 Junior high school
[] 3 Senior high school
[] 4 Vocational senior high school
[] 5 Diploma I/II
[] 6 Diploma III/bachelor
[] 7 Diploma IV/undergraduate
[] 8 Postgraduate
618. What is your highest grade of attended/attending education? (Completed = 7)
619. What is your highest level of education attainment?
[] 2 Primary school
[] 3 Junior high school
[] 4 Senior high school
[] 5 Vocational senior high school
[] 6 Diploma I/II
[] 7 Diploma III/bachelor
[] 8 Diploma IV/undergraduate
[] 9 Postgraduate
620. Are you able to read and write?
[] 2 No
[] 4 No
[] 6 Yes
[] 5 No
621. Do you have activities such as working, attending school, taking courses, etc. in another regency/municipality and routinely travel daily to and from this house?
[] 2 No [go to Q.626]
[Questions 622 - 625 were asked of persons age 5 or older who commute outside the regency, as per question 621.]
622. What is your primary activity there?
[] 2 Attending school
[] 3 Taking course
[] 6 Other (specify) ____
623. How far is the distance from your home to the place of activity?
624. How long does it take to get from your house to the place of activity?
625. What kind of transportation do you commonly use to and from the place of activity?
[] 2 No
[] 4 No
[] 6 No
[] 8 No
[] 1 No
[] 3 No
[] 5 No
[] 7 No
VI.C. Household members age 10 or older
[Questions 626 - 629 were asked of household members age 10 or older.]
626.a. Did you work during the past week for at least one hour in order to earn money or goods?
[] 2 No
626.b. Do you have work or business but temporarily you did not work during the past week?
[Question 626.b was asked of persons age 10 or older who did not work in the past week, as per question 626.a.]
[] 2 No [if age is younger than 60 years, go to next household member; if age is 60 years or older, go to Q.630]
[Questions 627 - 629 were asked of persons age 10 or older who had work in the past week, as per question 626]
627. Main industry of your work.
Filled by CBS _ _ _
628. Classification of occupation of main work.
Filled by CBS _ _ _
629. Employment status of main work
[] 2 Self employed assisted by temporary employee/unpaid employee
[] 3 Employer
[] 4 Regular employee
[] 5 Casual employee in agriculture
[] 6 Casual employee not in agriculture
[] 7 Unpaid worker
VI.D. Household member age 60 or older
[Questions 630 - 639 were asked of household members age 60 or older.]
630. In the last six months, did you receive money or goods from:
[] 2 No
[] 4 No
[] 6 No
[] 8 No
[] 1 No
[] 3 No
[] 5 No
[] 7 No
631. See Q. 630, if there is at least one "Yes" circled, ask: Which is the largest source among them?
[Question 631 is asked of persons age 60 or older who received money from any source listed, as per question 630.]
632. Is the income source enough to fulfill everyday necessities?
[] 2 No
633. According to you, what is your health status?
[] 2 Enough
[] 3 Unfavorable
634. Do you need and use an appliance to assist [you medically]?
[] 2 No
[] 4 No
[] 6 Yes
[] 8 No
[] 1 No
[] 3 No
635. If there is any "Need, yes" as well as "Use, no" in Q.634, ask: What is your reason for not using it?
[Question 635 was asked of persons age 60 or older who answered to needing an aid but not using it for any section of question 634.]
[] 2 Not available
[] 3 Other
[] 5 Not available
[] 6 Other
[] 8 Not available
[] 9 Other
636. In daily activities, do you need other people's help for:
[] 2 No
[] 4 No
[] 6 No
[] 8 No
[] 1 No
637. See Q.636: if there is any "Yes" circled, ask: Who assists you in:
[Question 637 was asked of persons age 60 or older who answered to need help in any part of question 636.]
[] 2 Children
[] 3 Other family
[] 4 Other people
[] 2 Children
[] 3 Other family
[] 4 Other people
[] 2 Children
[] 3 Other family
[] 4 Other people
[] 2 Children
[] 3 Other family
[] 4 Other people
[] 2 Children
[] 3 Other family
[] 4 Other people
638. In the last six months, did you:
[] 2 No
[] 4 No
[] 6 No
[] 8 No
[] 1 No
[] 3 No
[] 5 No
639. During the past month, which was your main [hobby]?
VII. Ever married women age 10 or older
[Questions 701 - 723 were asked of women age 10 or older who have ever been married.]
701. Name: ____
No. of household member _ _
702. In what month and year was your first marriage?
Year _ _ _ _
703. How old were you at your first marriage?
704. How many times have you been married?
705. How long have you been married?
706. See Q.405 (respondent's current marital status)
[] 2 Divorced [or] widowed [go to Q.708]
707. Is your husband a part of the household?
[Question 707 was asked of married women age 10 or older, as per question 706.]
708. How long have you lived without a husband?
[Question 708 was asked of divorced/widowed women age 10 or older, as per question 706.]
709. Have you ever used family planning methods?
[] 2 No [go to Q.717]
[Questions 710 - 711 were asked of women who have ever used family planning methods, as per question 709.]
710. What was your last family planning method?
[] 2 Male sterilization
[] 3 Pill
[] 4 IUD
[] 5 Injection, 1 month
[] 6 Injection, 3 months
[] 7 Implant, 3 years
[] 8 Implant, 5 years
[] 9 Condom
[] 10 Intra-vaginal/diaphragm
[] 11 Lactational amenorrhea method
[] 12 Periodic abstinence
[] 13 Withdrawal
[] 96 Other (specify) ____
711. See Q.405 (respondent's marital status)
[] 2 Divorced [or] widowed [go to Q.718]
712. Are you currently using any family planning method?
[Question 712 was asked of married women age 10 or older who have ever used family planning methods, as per questions 709 and 711.]
[] 2 No [go to Q.717]
713. What method are you using?
[Question 713 was asked of married women age 10 or older currently using family planning, as per questions 711 and 712.]
[] 2 Male sterilization
[] 3 Pill
[] 4 IUD
[] 5 Injection, 1 month
[] 6 Injection, 3 months
[] 7 Implant, 3 years
[] 8 Implant, 5 years
[] 9 Condom
[] 10 Intra-vaginal/diaphragm
[] 11 Lactational amenorrhea method [go to Q.718]
[] 12 Periodic abstinence [go to Q.718]
[] 13 Withdrawal [go to Q.718]
[] 96 Other (specify) ____ [go to Q.718]
[Questions 714-716 were asked of married women currently using the family planning methods of "Female sterilization", "Male sterilization", "Pill", "IUD", "Injection, 1 month", "Injection, 3 months", "Implant, 3 years", "Implant, 5 years", "Condoms", or "Intra-vaginal/diaphragm", as per questions 711-713.]
714. Where did you obtain the method the last time you used it?
[] 12 Village health clinic [puskesmas/pustu]
[] 13 Clinic
[] 14 Fieldworker [PLKB]
[] 15 Mobile unit [TKBK/TMK]
[] 16 Other (specify) ____
[] 22 Clinic
[] 23 Doctor
[] 24 Village midwife
[] 25 Pharmacy/drug store
[] 32 Health post [KB/PPKBD]
[] 33 P.P. post [IHC]
[] 34 Friend/relative
[] 35 Shop
[] 36 Other (specify) ____
715. When was the last time you used a family planning method?
Year _ _ _ _
716. Last time you used a family planning service, did you have to pay for it?
[] 2 No [go to Q.718]
717. What is your primary reason for not using a family planning method?
Fertility related reason
[] 12 Menopause/hysterectomy
[] 13 Sub-fecundity/infecundity
[] 14 Wants as many children as possible
[] 22 Husband opposed
[] 23 Other person opposed
[] 24 Religious prohibition
[] 32 Knows no source
[] 42 Fear of side effects
[] 43 Too far
[] 44 Cost too much
[] 45 Inconvenient
[] 46 Gain/loss weight
[] 98 Don't know
718. Have you ever given birth?
[] 2 No [go to Q.736]
719. How old were you at your first delivery?
[Questions 719 - 735 were asked of women who answered "Yes" in question 718.]
720. How many sons and daughters to whom you have given birth live with you?
_ _ Daughters
721. How many sons and daughters to whom you have given birth are alive but do not live with you?
_ _ Daughters
722. How many sons and daughters to whom you have given birth were alive but later died?
_ _ Daughters
723. Total number of sons and daughters
VII.D. Birth history of children
[Questions 724 - 735 were asked of every woman who ever delivered a baby]
724. What name was given to your (first/next) baby? ____
725. Were any of these births twins?
[] 2 Multiple
726. Is [the child] a boy or a girl?
[] 2 Girl
727. In what month and year was [the child] born?
Year _ _ _ _
728. Who assisted with the delivery of [the child]?
[] 2 Midwife
[] 4 Traditional birth attendant
[] 8 Other _ _
729. Is [the child] still alive?
[] 2 No [go to Q.732]
730. If alive, how old was [the child] at his/her last birthday?
[Questions 730 - 731 were asked of women who answered "Yes" in question 729.]
731. If alive, is [the child] living with you?
[] 2 No [go to Q. 733]
732. If dead, how old was [the child] when he/she died?
[Question 732 was asked of women who answered "No" in question 729.]
If "1 year" [is the answer given], probe: how many months old was (name)? Record [age] in days if younger than 1 month; in months, if younger than two years; or in years, if two years or older. If younger than 1 day, record "00" in days.
[] 2 Months _ _
[] 3 Years _ _
733. Were there any other live births between [the previous birth] and [this child]?
[Only applicable for second or further birth records]
[] 2 No
734. Have you had any live births since the birth of (name of last birth)?
[Question 734 was asked only if the last child referenced in question 724 was age 4 or older]
Subtract the year of the interview from the birth year of the last child. If [the child is] 4 years or older, ask [this question]:
[] 2 No
735. Was your husband with you when you delivered your last child?
[] 2 No
Give check sign in corresponding box.
1. Is Q. 603 relevant to Q. 703, Q.705, Q.708 and Q.719?
[] 2 Done
2. If Q.718 = 1, are Q.719 - Q.723 relevant?
[] 2 Done
3. If Q.718 = 1, is the last line of Q.724 relevant to Q.733?
[] 2 Done
4. If Q.729 = 1 is the child name already listed in Q.401?
[] 2 Done
5. Do the number of filled lines in Q.737 equal the number of total daughters in Q.736?
[] 2 Done
6. Are Q.739 - Q.743 relevant?
[] 2 Done
VII.E. List of female siblings
[Questions 736 - 743 were asked of all persons.]
736. How many children did your mother deliver?
_ _ Female
_ _ Total
737. What are your sisters' names? ____
738. Is she still alive?
[] 2 No
[] 8 Don't know [go to next sister record]
739. When did she die?
[Questions 739 - 743 were asked of persons who listed the name in 737 as "No" [not alive] in question 738.]
740. How old was she when she died?
741. Was she pregnant when she died, or did she die during childbearing?
[Questions 741 - 743 were asked of persons who listed an age of 10 and older when they died for the name listed in question 737.]
[] 2 No
742. Did she die within 42 days after the end of pregnancy?
[Question 742 was asked of persons who answered "No" in question 741 for the name listed in 737.]
[] 2 No [go to next sister record]
743. Did she die due to complication of pregnancy, delivery or postnatal period?
[Question 743 was asked of persons who answered "Yes" in question 741 or "Yes" in question 742 for the name listed in 737.]
[] 2 No