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Republic of Indonesia
2010 Population Census
Complete Enumeration for Household and Population

Set _ _ from _ _ set
_ pages

[Directions and an example of how to fill the form in the original document are not presented here.]

I. Identification

_ _ Province
_ _ Regency/municipality
_ _ _ Sub-district
_ _ _ Village
_ _ _ Census block no.
_ _ _ Local administrative unit serial no.
_ _ _ Physical building no.
_ _ _ Census building no.
_ _ _ Household serial no.

Address: ______

An ordinary household is a group of persons who usually live together in a building or housing unit who make common provision for food and other living essentials. A household could consist of only one household member.
Please ask about all persons who usually live and eat in this household; adults, children and/or persons who are away for fewer than six months and do not intend to move out of the household.
Record the numbers and names of all household members on the list of household members below.

List of household members

Usual residents
1. No. _ _ _
2. [Name]: ____
3. Relationship to head of household

[] 1 Head of household
[] 2 Spouse
[] 3 Child
[] 4 Adopted/step child
[] 5 Son/daughter in-law
[] 6 Grandchild
[] 7 Parent/parent in-law
[] 8 Other family
[] 9 Housemaid
[] 0 Others

4-5. Sex

Give check in the appropriate column.
[] 4. Male
[] 5. Female

Total males: _ _ _
Total females: _ _ _
Total of household members: _ _ _

Serial number of the informant: _ _ _

[The following questions are used for a check to ensure the enumerator has correctly included household members.]

Included household members:

Record the name in the list.

[] 1. Are there an infants or small children who have not been recorded?
[] 2. Are there any other persons who may not be family members such as housemaids, boarders, or friends who usually live here but have not been recorded?
[] 3. Are there any guests or temporary visitors in this household who already have left their house for six months or more but have not been recorded?
[] 4. Are there any persons who usually live here but currently are away for fewer than six months who have not been recorded?

Not included household members:

Cross out for the list.

[] 1. Are there any persons who have been recorded but have been away for six months or more?
[] 2. Are there any persons who have been recorded but have been away and intend to move?
[] 3. Are there any persons who have been recorded but have died during the enumeration period?
[] 4. Are there any children who have been recorded but currently working/studying and live in other places (ex.: rent a room)?

[The identification of the enumerator and related information in the original document are omitted here]

II. Personal characteristics

201. Name of household member? ____

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

[] 1 Head of household
[] 2 Spouse
[] 3 Child
[] 4 Adopted child/stepchild
[] 5 Son/daughter in-law
[] 6 Grandchild
[] 7 Parent/parent in-law
[] 8 Other family
[] 9 Housemaid
[] 0 Others

203. Is [the respondent] male or female?

[] 1 Male
[] 2 Female

204. On what day, month, and year was [the respondent] born?

_ _ Date
_ _ Month
_ _ _ _ Year

Age: _ _ years

205. What is [the respondent's] place of birth?

a. Province/state: ____ _ _
b. Regency/municipality: ____ _ _ _

206. What is [the respondent's] religion?

[] 1 Moslem
[] 2 Christian
[] 3 Catholic
[] 4 Hindu
[] 5 Buddhist
[] 6 Khonghucu
[] 7 Others (specify)

207. Does [the respondent] have difficulties in:

a. Seeing even when wearing glasses?
[] 1 No
[] 2 Some
[] 3 Total
b. Hearing even when using hearing aids?
[] 1 No
[] 2 Some
[] 3 Total
c. Walking or climbing stairs?
[] 1 No
[] 2 Some
[] 3 Total
d. Remembering, concentrating, or communicating with others because of a physical or mental condition?
[] 1 No
[] 2 Some
[] 3 Total
e. Take care of his/herself?
[] 1 No
[] 2 Some
[] 3 Total

208. What is [the respondent's] citizenship and ethnicity?

a. Indonesian, specify ethnicity: ____ _ _ _ _ _
b. Foreigner, specify country of citizenship: ____ _ _ _

For persons age 5 or older
[Questions 209-214 were asked of persons aged 5+.)

209. In which regency/city and province did [the respondent] live 5 years ago (May 2005)?

a. Province/state: ____ _ _
b. Regency/municipality: ____ _ _ _

210. What language does [the respondent] usually speak at home?

____ _ _ _ _ _

211. Is [the respondent] able to speak Indonesian?

[] 1 Yes
[] 2 No

212. What is the schooling status of [the respondent]?

[] 1 Never/not yet attending school (go to Q214)
[] 2 Attending school
[] 3 No longer attending school

[Questions 213-214 were asked of persons age 5 or older who have ever attended school.]

213. What is [the respondent's] highest level of education completed?

[] 1 Never/not yet completed primary school
[] 2 Primary school
[] 3 Junior high school
[] 4 Senior high school
[] 5 Vocational high school
[] 6 Diploma I/II
[] 7 Diploma III/Academy
[] 8 Diploma IV/Undergraduate
[] 9 Postgraduate

214. Is [the respondent] able to read and write:

a. Latin characters
[] 1 Yes
[] 2 No
b. Other characters
[] 1 Yes
[] 2 No

For persons age 10 or older
[Questions 215-218 were asked of persons age 10 or older.]

215. What is [the respondent's] marital status?

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

216. [The respondent's] activities during the previous week:

a. Working/carrying out activities?
Working/carrying out activities are doing activities to earn/help others to earn wages/salaries/profit for at least one hour.

[] 1 Yes (to Q217)
[] 2 No
b. Does he/she have a permanent job but is temporarily not working?
For example: waiting for harvesting, holidays, illness, etc.

[] 1 Yes (to Q217)
[] 2 No
c. Seeking work?
[] 1 Yes (to Q219)
[] 2 No
d. Available for work?
[] 1 Yes (to Q219)
[] 2 No (to Q219)

[Questions 217-218 were asked of persons age 10 or older who worked or were on temporary leave during the previous week.]

217. What was the type of main industry of [the respondent] during the previous week?

Specify as completely as possible, for example: rice and grain crop agriculture, driver in textile industry, driver in government office, teacher in state junior high school, motorcycle taxi, doctor in health center, etc.
____

Filled by Kortim in the field:
[] 01 Agriculture, rice, corn, other grains
[] 02 Agriculture, horticulture (vegetables, fruits, etc.)
[] 03 Agriculture, estate (palm, tea, tobacco, rubber, etc.)
[] 04 Agriculture, fishery (fishing, fish cultivation, etc.)
[] 05 Agriculture, animal husbandry (animals farming, dairy, etc.)
[] 06 Agriculture, other (forestry, hunting, etc.)
[] 07 Mining and quarrying
[] 08 Manufacturing
[] 09 Electricity and gas
[] 10 Construction (buildings, roads, bridges, etc.)
[] 11 Trade (wholesale and retail)
[] 12 Hotel and restaurant
[] 13 Transportation and storage
[] 14 Information and communications
[] 15 Finance and insurance
[] 16 Educational services
[] 17 Health services
[] 18 Other services (government, private, and individual)
[] 19 Others (real estate, water supply, etc.)

218. What was [the respondent's] employment status during the previous week?

[] 1 Self-employed
[] 2 Self-employed, assisted by unpaid temporary employees
[] 3 Employer, assisted by paid permanent employees
[] 4 Employee
[] 5 Casual worker
[] 6 Unpaid family worker

Ever married women age 10 or older
[Questions 219-221 were asked of ever-married women age 10 or older.]

219. Has [the respondent] ever had a live birth?

[] 1 Yes
[] 2 No (go to the next household member)

[Questions 220-221 were asked of ever-married women age 10 or older who had a live birth.]

220. How many of [the respondent's] children are:

a. Living in this household?
_ _ Sons
_ _ Daughters
b. Living elsewhere?
_ _ Sons
_ _ Daughters
a. Have died?
_ _ Sons
_ _ Daughters

221. Has [the respondent] had a live birth since 1 January 2009?

[] 1 Yes
[] 2 No

III. Mortality

301. Have there been any deaths in this household since 1 January 2009?

[] 1 Yes, how many?
[] 1 person
[] 2 persons
[] More than 3 persons (use additional SP2010-C1 questionnaire)
[] 2 No

302. Record the names of the deceased: ____

303. Sex of the deceased [person]?

[] 1 Male
[] 2 Female

304. In which month and year did [the person] die?

_ _ Month

[] 2009
[] 2010

305. How old was [the person] when he/she died?

Put "00" if younger than 1 year. Enter best estimate if the exact age is not known.

_ _ years

306. See Q303 and Q305: Was [the person] a woman age 10 or older?

If "No", skip to other [deceased person] or to Q401.

[] 1 Yes
[] 2 No

307. Did [the person] die during pregnancy, delivery, or within 2 months of pregnancy?

[Question 307 was asked of households with a death in the past year of a woman age 10 or older.]

If "No", skip to other [deceased person] or to Q401.

[] 1 Yes
[] 2 No (go to Q401)

308. If Q307 = "Yes": Did [the person] die during:

[Question 308 was asked of households with a death in the past year of a woman within two months of pregnancy.]

[] 1 Pregnancy
[] 2 Childbirth
[] 3 Within two months of pregnancy

IV. Housing Characteristics

401. What is the primary floor material?

[] 1 Ceramic/marble/granite
[] 2 Tiles/terrazzo
[] 3 Cement/bricks
[] 4 Wood/board
[] 5 Bamboo
[] 6 Dirt/earth
[] 7 Others

402. Floor area of this living quarter?

_ _ _ _ square meters

403. What is the primary source of lighting?

[] 1 State Electricity Company with meter
[] 2 State Electricity Company without meter
[] 3 Electricity not from the State Electricity Company
[] 4 No electricity

404. What is the main source of energy for cooking?

[] 1 Electricity
[] 2 LPG/National Gas
[] 3 Kerosene
[] 4 Charcoal
[] 5 Wood
[] 6 Others
[] 7 None

405. What is the main source of drinking water?

[] 1 Bottled water
[] 2 In-house piped water system
[] 3 Piped water outside dwelling/retail
[] 4 Pumped water
[] 5 Protected well
[] 6 Unprotected well
[] 7 Protected spring
[] 8 Unprotected spring
[] 9 River
[] 10 Rain water
[] 11 Others

406. What type of toilet facility?

[] 1 Private toilet
[] 2 Shared toilet
[] 3 Public toilet
[] 4 No toilet facility (go to Q408)

407. What kind of excreta disposal does the toilet use?

[Question 407 was asked of households with a toilet facility.]

[] 1 With septic tank
[] 2 Without septic tank
[] 3 No disposal facility

408. What kind of telephone does this household have?

[] 1 Land line telephone
[] 2 Cellular telephone
[] 3 Land line and cellular telephone
[] 4 No telephone

409. Is there any household member who accessed the Internet during the last three months?

[] 1 Yes
[] 2 No

410. What is the ownership status of this dwelling/living quarter?

[] 1 Owned
[] 2 Rented
[] 3 Leased
[] 4 Others

[If responses 2-4, stop].

411. Does this household have proof of land ownership of this dwelling unit?

[Question 411 was asked of households who indicate owning the dwelling.]

[] 1 Yes
[] 2 No (stop)

412. What kind of proof of land ownership of this dwelling unit?

[Question 412 was asked of household who have proof of ownership of the dwelling.]

[] 1 Ownership Certificate (SHM) belonging to HH member
[] 2 Ownership Certificate (SHM) not belonging to HH member
[] 3 Other Certificate (SHGB, SHP, SSRS)
[] 4 Others (Girik, Akte Jual Beli Notaris/PPAT, etc.)