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Royal Government of Cambodia
General Population Census of Cambodia
1998

___ Page Number
___ Total number of pages for the E.A.

STRICTLY CONFIDENTIAL

Identification Particulars (Name and Code)

___ Khet / Krong
___ Srok / Khand
___ Khum / Sangkat
___ Phum / Mondol
___ Enumeration Area No.

Building / Structure and Household Particulars

___ 1 Line No.

___ 2 Building / Structure number

Predominant construction material of Building/Structure*

3 Wall Material (Column 3, Enter Code)

1 Bamboo / Thatch / Grass / Reeds
2 Earth
3 Wood / Plywood
4 Concrete / Brick / Stone
5 Galvanised iron / Aluminium / Other metal sheets
6 Asbestos cement sheets
7 Salvaged / Improvised materials
8 ___ Other (specify)

4 Roof Material (Column 4, Enter Code)

1 Bamboo / Thatch / Grass
2 Tiles
3 Wood / Plywood
4 Concrete / Brick / Stone
5 Galvanised iron / Aluminium / Other metal sheets
6 Asbestos cement sheets
7 Plastic / Synthetic material sheets
8 ___ Other (specify)

5 Floor Material (Column 5, Enter Code)

1 Earth / Clay
2 Wood / Bamboo planks
3 Cement / Brick / Stone
4 Polished stone
5 Parquet / Polished wood
6 Mosaic / Ceramic tiles
7 ___ Other (specify)

6. Purpose of Building/ Structure (Enter Code)

1 Residence
2 Residence and Shop Household No.
3 Residence and Workshop
4 Residence and any other establishment (specify)

7 ___ Household No.

8 Particulars of Head of Household

___ Name

9 Sex (Enter Code)

1 Male
2 Female

Number of persons usually living in the household
___ 10 Males
___ 11 Females
___ 12 Persons

Count the number of entries and give total [applies to question 7, 10-12]
___ [Households]
___ [Males]
___ [Females]
___ [Persons]

___ 13 Remarks

___ Name of Enumerator
___ Signature
___ Date

___ Name of Supervisor
___ Signature
___ Date

STRICTLY CONFIDENTIAL

Form B: Household Questionnaire Part 1

Identification Particulars (Name and Code)

___ Khet / Krong
___ Srok / Khand
___ Khum / Sangkat
___ Phum / Mondol
___ Enumeration Area No.
___ Building No.
___ Household No.
___ Name of Head of Household

Type of Household / Population (Give appropriate code in the box below)

1 Normal or Regular Household
2 Institutional household *
3 Homeless Household *
4 Boat Population *
5 Transient Population * ___ (Specify location)

* In these cases [], fill-in only Identification Particulars. Population Particulars in Statements 1.1, 1.2 and 1.3 are not to be collected in these cases.

Population Particulars

Statement 1.1: Usual Members Present on Census Night

[Questions 1-4 in Statement 1.1 are the same as questions 1-4 in Part B]

Statement 1.2: Visitors Present on Census Night
[Questions 1-4 in Statement 1.2 are the same as questions 1-4 in Part B]

Usual Residance

___ 5 Within Cambodia (Give name of district and write name of province within brackets)

___ 6 Outside Cambodia (Give name of country)

Statement 1.3: Usual Members Absent on Census Night

[Questions 1-5 in Statement 1.2 are the same as questions 1-5 in Part B]

Location on Census Night
___ 6 Within Cambodia (Give name of district and write name of province within brackets)

___ 7 Outside Cambodia (Give name of country)

___ 8 How long Absent (in completed months. Write 0 for less than 1 month)

___ Total No. of Persons in Statement 1.1
___ Total No. of Persons in Statement 1.2
___ Total No. of Persons in Statements 1.1 and 1.2
___ Number of Form B used for the Household

Enumerator

___ Name
___ Signature
___ Day ___ Month ___ Year

Supervisor

___ Name
___ Signature
___ Day ___ Month ___ Year

Form B: Household Questionnaire Part 2: Individual Particulars

For all persons
[Applies to questions 1-20]

___ 1 Sl. No.
___ 2 Full Name - Names of Usual Members Present and Visitors (Please refer to Statements 1.1 and 1.2 in Part 1)

___ 3 Relationship - Relationship to Head of Household (Enter Code from list below)
Codes for Column 3 Relationship to Head of Household

[] 1 Head
[] 2 Wife / Husband
[] 3 Son / Daughter
[] 4 Father / Mother
[] 5 Grand Child
[] 6 Other Relative
[] 7 Non-relative

4 Sex (Enter Code)

[] 1 Male
[] 2 Female

5 Age (Age in completed years)

[] 00: Less than 1 year
[] 01: 1 year
[] 02: 2 years
.
.
[] 97: 97 years
[] 98: 98 years and over

6 Marital Status (Marital Status - Enter Code))

[] 1 Never Married
[] 2 Married
[] 3 Widowed
[] 4 Divorced
[] 5 Separated

7 Mother Tongue

[] 1 Khmer
[] 2 Vietnamese
[] 3 Chinese
[] 4 Lao
[] 5 Thai
[] 6 French
[] 7 English
[] 8 ___ Other (specify)

8 Religion

[] 1 Buddhism
[] 2 Islam
[] 3 Christianity
[] 4 Other (specify)

9 ___ Birth Place

Place of Birth
[If in this village, enter code 1.
If in another village, give name of district of that village and write name of province within brackets.
If outside Cambodia, write name of country.]

10 Previous Residence

Where have you been living before?
If always lived in this village, enter code 1 and skip to 13.
If in another village, give name of district of that village and write name of province within brackets.
If outside Cambodia, write name of Country.

11 Duration of Stay

How long have you lived in this village? (Enter Code from list below)
Codes for Column 11 Duration of Stay

00 Less than 1 year
01 1 to less than 2 years
02 2 to less than 3 years
.
.
10 10 to less than 11 years
.
20 20 to less than 21 years
.
97 97 to less than 98 years
98 98 years and over.

12 Reason for Migration

Give reason for change of residence, if present residence is different from previous residence. (Enter Code from list below)
Codes for Column 12 Reason for Migration

1 Transfer of work place
2 In search of employment
3 Education
4 Marriage
5 Family moved
6 Natural calamities or insecurity
7 Repatriation or return after displacement
8 Visiting only
9 ___ Other (specify)

13 Literacy (Enter Code)

Can you read and write with understanding in any language?
[] 1 Yes
[] 2 No

14 Full-Time Education

( a ) Have you ever attended School/ Educational Institution? (Enter Code)
1 Never
2 Now
3 Past
( b ) What is the highest grade completed? (Enter Code from list below)
Codes for Column 14 (b) What is the highest grade completed?

For Never in 14 (a) put dash ( - )
For Now or Past in 14 (a), Code as follows:-
00 No class completed
01 Class 1 completed
02 Class 2 completed
.
.
11 Class 11 completed
12 Class 12 completed
13 Secondary School / Certificate / Diploma
14 Undergraduate
15 Graduate / Degree holder
16 Postgraduate
17 ___ Other (specify)

15 Main Activity (Enter Code from list below)

Main activity during last year

Codes for Column 15 Main Activity During Last Year
1 Employed (Fill in Cols. 16 to 20)
2 Unemployed (Employed any time before - Fill in Cols. 16 to 20 for last employment)
3 Unemployed (Never employed any time before)
Inactive
4 Homemaker
5 Student
6 Dependent
7 Rent-receiver, retired or other income recipient
8 ___ Other (Specify)
(For codes 3 to 8, put dash ( - ) in Cols. 16 to 20)]

___ 16 Employment Period (No. of months employed in the last 12 months)

___ 17 Occupation (Name of Occupation)

18 Employment Status

Employment Status / Class (Enter Code from list below)
1 Employer
2 Paid employee
3 Own - account worker
4 Unpaid family worker
5 ___ Other (specify)

___ 19 Industry, Trade or Service (Nature of Industry, Trade or Service)

20 Sector of Employment (Sector in which Employed) (Enter Code from list below)

Codes for Column 20 Sector of Employment

1 Government
2 State-owned enterprise (Parastatal)
3 Cooperative
4 Private
5 ___ Other (specify)

Form B: Household Questionnaire Part 3: Fertility Information of Females Aged 15 and Over Listed in Column 2 of Part 2

___ 1 Sl. No.
___ 2 Full Name
___ 3 Sl. No. in Col. 1 of Part 2

Fertility Information

_ _ 4 Number of Children Born(Give number in two digits like 01, 02,...................10, 11 etc. If none, write 00)

How many children have been born alive to the woman ?
_ _ (a) Male
_ _ (b) Female

How many of them are living?
_ _ (c) Male
_ _ (d) Female

How many of them have died?
_ _ (e) Male
_ _ (f) Female

5 Particulars of Birth in the last 12 months

Any child born alive to the woman during the last 12 months?
(Give actual number like 1,2,... If none, write 0)
_ Male
_ Female

Form B Household Questionnaire Part 4: Housing Conditions and Facilities** (Enter Code in the box below)

**Part 4 need not be filled-in for Institutional and Homeless Households and for Boat and Transient Population.
1 On what basis does the household occupy this dwelling?

1 Owner occupied
2 Rent
3 Not owner, but rent free
4 ___ Other (specify)
[ ]

2 Main source of light

1 City power
2 Generator
3 Both city power and generator
4 Kerosene
5 Candle
6 Battery
7 ___ Other (specify)
[ ]

3 Main cooking fuel

1 Firewood
2 Charcoal
3 Kerosene
4 Liquefied Petroleum Gas (LPG)
5 Electricity
6 None
7 ___ Other (specify)
[ ]

4 Toilet facility within premises

1 Available
2 Not available
[ ]

5 Main source of drinking water supply

1 Piped water
2 Tube / pipe well
3 Dug well
4 Spring, river, stream, lake / pond, rain
5 Bought
6 ___ Other (specify)
[ ]

6 No. of rooms occupied by household (exclude kitchen, bathroom, toilet and storeroom)

1 One Room
2 Two Rooms
3 Three Rooms
4 Four Rooms
5 Five Rooms
6 Six Rooms
7 Seven Rooms
8 Eight Rooms and above

[ ]