Form 2 - Household Questionnaire

Does the household questionnaire have one or more sheets?
Sheet number ____ of ____sheets

____ Oastan (Province)
____ Shahrestan (sub-province)
____ Bakhsh (county)
____ Shahr / Dehestan (city / agglomeration)
____ Village
____ Block number/Village code
____ District number

Number of household members
_ _ Male
_ _ Female
_ _ Number of 17-year persons and younger
_ _ Number of persons aged 18 and over

Household type

Household line number (From column 10 Form 1) _ _
For rural areas: Full name of household head's father ____
Main place number _ _
Address of household residence (district, number of residence, floor and unit should be written) ____
Postal code _ _ _ _ _ _ _ _ _ _

____ Full name of census enumerator
____ Full name of the group expert
____ Full name of the technical editor
____ Full name of the editing expert

Columns 3, 37, and 38 are not for collective households and should be left blank for them

Columns 9 to 16 and columns 22, 29, and 39 are completed for unsettled private households and should be left blank for others

For all household members (Questions 1-9)
[Household members should be sorted based on codes of column 3]

1. Age _ _

2. Full name ____

National Card Number _ _ _ _ _ _ _ _ _ _

3. Relationship to head of the household

4. Sex

Birth date

7. Age at last birthday _ _

8. Residence status

9. Does he/she reside in another place?

Questions 10-16 for those whose residence status is present or temporarily absent

For those who responded "yes, in the same village" or city or "yes, in other city" to question 9
10. How long has the person lived in the second residence?

11. Has she/he changed his/her residences since 2006?

For persons who answered yes to question 11
12. Length of residence in the same city or village in full years _ _

13. Reason for change of previous residence

14. Previous residence

For those living in another Shahrestan sub-province from question 14
15. Name of the Shahrestan (sub-province) of the previous residence, for abroad name of country ____

For all answers except abroad in question 14
16. Has she/he changed her/his residence from abroad to the inside country since Nov. 2006 ____

For persons aged 6 and over

17. Has she/he used the internet at least once during the last 12 months?

18. Is he/she attending school / university?

19. Literacy status

20. Grade and educational attainment

21. Field of Study

For present and temporarily absent from question 8 and those who are presently attending school / university in Iran

22. Place of education

Activity and marital status - For people aged 10 and over

23. Activity status during the last 7 days

For those who did not work during the last 7 days
24. Status of seeking work during the last 30 days

For those who are seeking work or has not been seeking
25. Status of availability to work

Questions 26-28 for those who are working, doing unpaid work in the household business, or are temporarily absent from work

26. Main activity of the work place (It should be avoided to write general titles such as office, company, factory, supermarket, shop ...) _____

27. Job (It should be avoided to write general titles such as clerk, farmer, and self-employment) ____

28. Job status

29. (For those present or temporarily absent from question 8)
Work Place

30. Marital status

Fertility status - for women aged 10 and over who have been married, widowed, or divorced from question 30

31. Has she ever given a live birth?

[Questions 32-36 for those who answered yes to question 31]

32. Number of children ever born (in total)

33. Number of children born, still living

Questions 34-36 for women aged 10 to 54

34. Has she given a live birth during the last 365 days?

Questions 35-36 for yes to question 34

35. Number of children born alive during the last 365 days (in total)

36. Number of children born alive during the last 365 days, still living

For all household members

37. Is the mother a member of this household?

Question 38 is for those whose mothers are a member of this household

38. Line number of mother in column 1 _ _

39. Place of birth (mother's place of residence at the time of delivery):

40. Is there anybody in the household with at least one of the following disabilities?

41. Religion

42. Citizenship

Questions 43 to 59 should be completed for private settled and collective households

Death event in household

43. Has any person died in the household?

If the respondent answered yes to question 43, answer question 43.1 and 43.2

43.1 Is the dead person a girl / woman?

43.2 Is the dead person between the ages of 10 and 60?

Agricultural holding

44. In what activities is the household engaged?

Household facilities and housing

45. Are the following facilities available to the household?
1. Motorcycle with gearbox and moped

2. Light automobile (car, pickup, etc.)

3. Personal computer

46. Major fuel used by the household:

47. Main source of water supply used by the household:

48. Type of household residence

Questions 49-59 for households residing in apartments or non-apartment dwellings

49. Type of tenure of housing unit

50.
_ _ Number of rooms
_ _ Number of halls
_ _ Number or dining rooms
_ _ Number of kitchens

51. How many households live in this housing unit?

52. Has this form already been completed for a household?

53. Which of the following facilities are available to the housing unit?

54. Number of rooms, hall, dining room, open kitchen, closed kitchen and other in this housing unit:


55. Floor area of the housing unit

56. Type of housing unit skeleton

Question 57 is only for those who answered "other" in question 56

57. Main construction materials of the housing unit:

58. Year of the construction completion of the housing unit:

59. Type of sewage disposal in the housing unit

60.
____ Line number of respondent
____ Household telephone number
Interview date
2011/Nov/ _ _