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2011 Population and Housing Census

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

[] 1 Settled private
[] 2 Unsettled
[] 3 Collective

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

[] 1 Head of household
[] 2 Spouse
[] 3 Son/daughter
[] 4 Son/daughter in low
[] 5 Grandchild or great grandchild
[] 6 Father or mother
[] 7 Brother or sister
[] 8 Spouse's parents
[] 9 Spouse's brother or sister
[] 10 Other relatives
[] 11 Non-relatives

4. Sex

[] Male
[] Female

Birth date

_ _ 5. Month
_ _ 6. Year

7. Age at last birthday _ _

[] Lunar calendar (check if date of birth is stated in the lunar calendar)
[] Under one year
[] Aged 100 or over

8. Residence status

[] 1 Present
[] 2 Temporarily absent
[] 3 Abroad for work or education
[] 4 Other

9. Does he/she reside in another place?

[] 1 Yes, in the same village or city
[] 2 Yes, in other city, cite it ____
[] 3 Yes, in other village ____
[] 4 No

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?

[] 1 Less than three months
[] 2 Three to six months

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

[] Yes
[] No

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

[] 1 Seeking job
[] 2 Looking for a better job
[] 3 Job transfer
[] 4 Education
[] 5 Being graduate
[] 6 Military service
[] 7 End of military service
[] 8 Following the household
[] 9 Other

14. Previous residence

Elsewhere in the same Shahrestan (sub-province)
[] 1 City
[] 2 Village
Another Shahrestan (sub-province)
[] 3 City
[] 4 Village
[] 5 Abroad

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?

[] 1 Yes, at home
[] 2 Yes, at work
[] 3 Yes, at educational institutes
[] 4 Yes, at coffee net
[] 5 Yes, at other
[] 6 No

18. Is he/she attending school / university?

[] 1 Yes, in Iran
[] 2 Yes, abroad
[] 3 No

19. Literacy status

[] 1 Literate
[] 2 Illiterate

20. Grade and educational attainment

Grade for school students; educational course for university students; the highest grade or educational attainment for other people ____

21. Field of Study

For grade, course or educational attainment in question 20 ____

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

22. Place of education

[] 1 In the same city or village
[] 2 In over city, mention the name ____
[] 3 In other village

Activity and marital status - For people aged 10 and over

23. Activity status during the last 7 days

[] 1 Worked during the last 7 days
[] 2 Unpaid work in the household business
[] 3 Temporarily absent from work
[] 4 Did not work 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

[] 1 Seeking work
Not seeking work due to:
[] 2 Starting work in future
[] 3 Has not been working, waiting to return to previous work
[] 4 Education
[] 5 Homemaker
[] 6 Income recipient
[] 7 Other

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

[] 1 Available to work
[] 2 Not available to work due to education
[] 3 Homemaker
[] 4 Income recipient
[] 5 Other

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

[] 1 Employer
[] 2 Own-account, wage, and salaried worker
[] 3 Public sector
[] 4 Private sector
[] 5 Cooperative sector
[] 6 Unpaid family worker

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

[] 1 In the same city or village
[] 2 In other city, mention the name _____
[] 3 In other village

30. Marital status

[] 1 Married
[] 2 Widowed
[] 3 Divorced
[] 4 Never married

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?

[] Yes
[] No

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

32. Number of children ever born (in total)

_ _ Boys
_ _ Girls

33. Number of children born, still living

_ _ Boys
_ _ Girls

Questions 34-36 for women aged 10 to 54

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

[] Yes
[] No

Questions 35-36 for yes to question 34

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

_ _ Boys
_ _ Girls

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

_ _ Boys
_ _ Girls

For all household members

37. Is the mother a member of this household?

[] Yes
[] No

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):

[] 1 The same city / village
[] 2 Another city
[] 3 Another village
[] 4 Abroad

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

[] Yes, the following items should be completed for all household members
[] 1 Blind
[] 2 Deaf
[] 3 Voice and speech disorder
[] 4 Hand amputation
[] 5 Hand impairment
[] 6 Leg amputation
[] 7 Leg impairment
[] 8 Torso impairment
[] 9 Mental disorder
[] No, the columns should be left blank

41. Religion

[] 1 Moslem
[] 2 Christian Assyrian and Chaldean
[] 3 Armenian
[] 4 Other Christians
[] 5 Jewish
[] 6 Zoroastrian
[] 7 Other

42. Citizenship

[] 1 Iran
[] 2 Afghanistan
[] 3 Iraq
[] 4 Pakistani
[] 5 Turkey
[] 6 Other countries

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?

[] Yes
[] No, continue with question 44

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

43.1 Is the dead person a girl / woman?

[] Yes
[] No

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

[] Yes
[] No

Agricultural holding

44. In what activities is the household engaged?

[] 1 Farming (at least 400 m^2)
[] 2 Horticulture (at least 200 m^2)
[] 3 Livestock and poultry (at least 2 small livestock, at least one large livestock, at least 10 poultries, raising of honeybees in any number, raising of silkworms in any number)
[] 4 Greenhouse production
[] 5 None

Household facilities and housing

45. Are the following facilities available to the household?

1. Motorcycle with gearbox and moped

[] Yes
[] No

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

[] Yes
[] No

3. Personal computer

[] Yes
[] No

46. Major fuel used by the household:

Cooking
[] 1 Natural gas (public network)
[] 2 Liquid gas
[] 3 Burning oil
[] 4 Gas oil
[] 5 Electricity
[] 6 Solid fuel (firewood, charcoal, animal waste, etc.)
[] 7 Other fuels
[] 8 None
Heating
[] 1 Natural gas (public network)
[] 2 Liquid gas
[] 3 Burning oil
[] 4 Gas oil
[] 5 Electricity
[] 6 Solid fuel (firewood, charcoal, animal waste, etc.)
[] 7 Other fuels
[] 8 None
Providing warm water
[] 1 Natural gas (public network)
[] 2 Liquid gas
[] 3 Burning oil
[] 4 Gas oil
[] 5 Electricity
[] 6 Solid fuel (firewood, charcoal, animal waste, etc.)
[] 7 Other fuels
[] 8 None

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

Drinking
[] Public reservoir of city or village
[] Well, spring, aqueduct and improved water reservoir
[] Well, spring, aqueduct and unimproved reservoir
[] Mobile water tank
[] River, pool, brooks and rain water
[] Others
[] None
Cooking
[] Public reservoir of city or village
[] Well, spring, aqueduct and improved water reservoir
[] Well, spring, aqueduct and unimproved reservoir
[] Mobile water tank
[] River, pool, brooks and rain water
[] Others
[] None

Other uses
[] Public reservoir of city or village
[] Well, spring, aqueduct and improved water reservoir
[] Well, spring, aqueduct and unimproved reservoir
[] Mobile water tank
[] River, pool, brooks and rain water
[] Others
[] None

48. Type of household residence

[] 1 Apartment
[] 2 Non-apartment housing unit (conventional)
[] 3 Tent
[] 4 Straw hut (Kapar)
[] 5 Hut and the like
[] 6 Other

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

49. Type of tenure of housing unit

[] 1 Owned land and building
[] 2 Owned building
[] 3 Rented
[] 4 Against service
[] 5 Rent free
[] 6 Other

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

51. How many households live in this housing unit?

[] One household, continue with question 53
[] More than one household
Number of households: ____

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

[] Yes, line number of household _____, continue with question 60
[] No

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

Electricity
[] 1 Available
[] 2 Not available

Fixed telephone
[] 1 Available
[] 2 Not available
Piped water
[] 1 Available
[] 2 Not available

Central heating system (package, shofezh)
[] 1 Available
[] 2 Not available

Central heating and cooling system (fan coil, panel, ....)
[] 1 Available
[] 2 Not available
Kitchen
[] 1 Available
[] 2 Not available

Bathroom
[] 1 Available
[] 2 Not available

Toilet
[] 1 Available
[] 2 Not available

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

_ _ Rooms
_ _ Hall and dining room
_ _ Open kitchen
_ _ Closed kitchen
_ _ Other

55. Floor area of the housing unit

[] 1 50 square meters or less
[] 2 51-75 square meters
[] 3 76-80 square meters
[] 4 81-100 square meters
[] 5 101-150 square meters
[] 6 151-200 square meters
[] 7 201-300 square meters
[] 8 301-500 square meters
[] 9 501 square meters and more

56. Type of housing unit skeleton

[] 1 Metal
[] 2 Reinforced concrete
[] 3 Other

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

57. Main construction materials of the housing unit:

[] 1 Brick and steel or stone and steel
[] 2 Brick and wood or stone and wood
[] 3 Cement blocks (Roof of any kind)
[] 4 All brick or stone and brick
[] 5 All wood
[] 6 Sun dried brick and wood
[] 7 Sun dried brick and mud
[] 8 Other, mention the type ____

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

[] 1 2011
[] 2 2010
[] 3 2009
[] 4 2008
[] 5 2007
[] 6 2006
[] 7 1996-2005
[] 8 1986-1995
[] 9 1976-1985
[] 10 1966-1975
[] 11 Before 1966

59. Type of sewage disposal in the housing unit

Toilet
[] 1 Public sewage
[] 2 Private sewage
[] 3 Absorbing well
[] 4 Septic tank
[] 5 Area around the unit
[] 6 Other, mention the type ____
Kitchen
[] 1 Public sewage
[] 2 Private sewage
[] 3 Absorbing well
[] 4 Septic tank
[] 5 Area around the unit
[] 6 Other, mention the type ____

Other
[] 1 Public sewage
[] 2 Private sewage
[] 3 Absorbing well
[] 4 Septic tank
[] 5 Area around the unit
[] 6 Other, mention the type ____

60.
____ Line number of respondent
____ Household telephone number

Interview date
2011/Nov/ _ _