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Royal Government of Cambodia
Cambodia Intercensal Population Survey, 2004

Form A: House list

Identification Particulars

Khet / Krong

[] Name ____
[] Code _ _

Srok / Khand

[] Name ____
[] Code _ _

Khum / Sangkat

[] Name ____
[] Code _ _

Phum / Mondol

[] Name ____
[] Code _ _

[] Sample EA No _ _
[] No of households in the EA _ _ _

Building / structure and household particulars

[1] Line No

Numbered 1-10 per page.

[2] Building/Structure number _ _ _

Predominant construction material of building/structure

[3] Wall
[] 1 Bamboo / thatch / grass / reeds
[] 2 Earth
[] 3 Wood / plywood
[] 4 Concrete / brick / stone
[] 5 Galvanised iron / aluminum / other metal sheets
[] 6 Asbestos cement sheets
[] 7 Salvaged / improvised materials
[] 8 Other [specify] ____

[4] Roof
[] 1 Bamboo / thatch / grass
[] 2 Tiles
[] 3 Wood / plywood
[] 4 Concrete / brick / stone
[] 5 Galvanised iron / aluminum / other metal sheets
[] 6 Asbestos cement sheets
[] 7 Plastic / synthetic material sheets
[] 8 Other [specify] ____

[5] Floor
[] 1 Earth / clay
[] 2 Wood / bamboo plants
[] 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 for all.

[] 1 Residence
[] 2 Residence and shop
[] 3 Residence and workshop
[] 4 Residence and any other establishment [specify] ____

[7] Household No _ _

Particulars of head of household

[8] Name ____

[9] Sex

Enter code.
[] 1 Male
[] 2 Female

Number of persons usually living in the household

____ 10. Males
____ 11. Females
____ 12. Persons

[13] Remarks ____

[14] Serial no of household _ _ _

Enumerator

____ Name
____ Signature
____ Date

Supervisor

____ Name
____ Signature
____ Date

Form B

Form B: Household questionnaire Part 1

Identification Particulars

Khet / Krong

[] Name ____
[] Code _ _

Srok / Khand

[] Name ____
[] Code _ _

Khum / Sangkat

[] Name ____
[] Code _ _

Phum / Mondol

[] Name ____
[] Code _ _

Sample EA No ____ _ _
Building No ____ _ _ _
Household No ____ _ _

Name of head of household ____

SI no of household selected [copy from column 14 of Form A] _ _ _

Population particulars

Statement 1.1: Usual members present on survey night

[1] SI No _

[2] Full name ____

[3] Relationship to head of household ____

[4] Sex

Enter code.

[] 1 Male
[] 2 Female

Statement 1.2: Visitors present on survey night

[1] SI No _

[2] Full name ____

[3] Relationship to head of household ____

[4] Sex

[Enter code]

[] 1 Male
[] 2 Female

Usual residence

[5] Within Cambodia:
Give name of district and write name of province within brackets
____ District
____ Province
[6] Outside Cambodia:
Give name of country ____

Statement 1.3: Usual members absent on survey night

[1] SI No _

[2] Full name ____

[3] Relationship to head of household ____

[4] Sex:

Enter code.

[] 1 Male
[] 2 Female

[] Location on survey night

[6] Within Cambodia:
Give name of district and write name of province within brackets

____ District
____ Province
[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

Enumerator

____ Name
____ Signature
____ Day
____ Month
____ Year

Supervisor

____ Name
____ Signature
____ Day
____ Month
____ Year

Form B: Household questionnaire Part 2

Individual particulars
For all persons
[Questions 1 to 6 were asked of all persons]

[1] SI No _

[2] Full name ____

Names of usual members present and visitors [Please refer to statement 1.1 and 1.2 in part 1]

[3] Relationship

Relationship to head of household

Enter code from list below.

[] 1 Head
[] 2 Wife / husband
[] 3 Son / daughter
[] 4 Stepchild
[] 5 Adopted / foster child
[] 6 Father / mother
[] 7 Sibling
[] 8 Grand child
[] 9 Niece / nephew
[] 10 Son / daughter-in-law
[] 11 Brother / sister-in-law
[] 12 Father / mother-in-law
[] 13 Other relative
[] 14 Servant
[] 15 Non-relative including boarder

[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] Mother

Is your mother [i.e. natural mother] alive?

[] 1 Yes [for persons aged 15 and over skip to column 8]
[] 2 No [skip to column 8]
[] 3 Don't know [skip to column 8]

[7] Whether living with own mother _ _

For persons aged 0-14

Write serial number of natural mother [if living in this household] for a child aged 0-14. If mother not living in the household write "0".

[8] Marital status

For all persons. Enter code.

[] 1 Never married [skip to column 10]
[] 2 Married
[] 3 Widowed
[] 4 Divorced
[] 5 Separated

[9] Age at first marriage _ _

For other than never married

Age at first marriage [in completed years] [Ask married, widowed, divorced and separated person]

For all persons
[Questions 10 to 23 were asked of all persons]

[10] Mother tongue

What is your mother tongue?

Enter code located at the bottom page.

[] 01 Khmer
[] 02 Vietnamese
[] 03 Chinese
[] 04 Lao
[] 05 Thai
[] 06 French
[] 07 English
[] 08 Korean
[] 09 Japanese
[] 10 Chaaraay
[] 11 Chaam
[] 12 Kaaveat
[] 13 Klueng
[] 14 Kuoy
[] 15 Krueng
[] 16 Lon

[11] Religion

[] 1 Buddhism
[] 2 Islam
[] 3 Christianity
[] 4 Other [specify] ____

[12] Place of birth

[] 1 In this village
[] In another village
Give the name of the district of that village and write name of province within brackets ____ _ _ _ _
[] Outside Cambodia
Write the name of the country ____ _ _ _ _

[13] Previous residence

Where has the person been living before?

[] 1 Always lived in this village (skip to column 16)
[] In another village
Give name of the district of that village and write name of province within brackets ____ _ _ _ _
[] Outside Cambodia
Write name of the country ____ _ _ _ _

[Questions 14 and 15 were asked of persons who ever lived outside the village where they are currently residing, as per question 13]

[14] Duration of stay

How long have you lived in this village? Enter code from the list below [not all the possible responses are represented.]

[] 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

[15] Reason for migration

Give reason for a change of residence, if present residence is different from previous residence. Enter code from list below.

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

[16] Literacy

Can you read and write with understanding in any language?

Enter code.

[] 1 Yes
[] 2 No

[17] 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?

[Question 17b was asked of persons currently attending school]

Enter code from the list below
For "Never" in 17 (a) put dash (-) in17 (b). For "Now" or "Past" in 17 (a), code as follows [not all the possible responses are represented]:

[] 88 No class completed
[] 00 Pre-school/kindergarten
[] 01 Class 1 completed
[] 02 Class 2 completed
[] 11 Class 11 completed
[] 12 Class 12 completed (without bac)
[] 13 Secondary school / baccalaureate holder
[] 14 Technical / vocational pre-secondary diploma/certificate
[] 15 Technical / vocational post-secondary diploma/certificate
[] 16 Undergraduate
[] 17 Graduate / degree holder
[] 18 Postgraduate
[] 19 Master's degree
[] 20 Post-master's degree
[] 21 Ph.D.
[] 22 Other (specify) ____

[18] Main activity

Main activity during last year

Enter code from list below.

[] 1 Employed [fill in columns 19 to 23]
[] 2 Unemployed (employed any time before) [fill in cols. 19 to 23 for last employment]

[For codes 1 or 2, continue to questions 19 to 23 and response according to present or last employment]

[] 3 Unemployed (never employed any time before)

Inactive
[] 4 Home maker
[] 5 Student
[] 6 Dependent
[] 7 Rent-receiver, retired or other income recipient
[] 8 Other (specify) ____

[For codes 3 to 8, put dash (-) in Cols. 19 to 23]

[19] Employment period _ _

[Question 19 asked of persons who responded codes 1 and 2 in question 18.]

Number of months employed in the last 12 months

[20] Occupation ____ _ _ _

[Question 20 asked of persons who responded codes 1 and 2 in question 18.]

Name of occupation

[21] Employment status

[Question 21 asked of persons who responded codes 1 and 2 in question 18.]

Employment status/class

Enter code from list below.

[] 1 Employer
[] 2 Paid employee
[] 3 Own-account worker
[] 4 Unpaid family worker
[] 5 Other (specify) ____

[22] Industry, trade or service ____ _ _ _

[Question 22 asked of persons who responded codes 1 and 2 in question 18.]

Nature of industry, trade or service

[23] Sector of employment

Sector in which employed

[Question 23 asked of persons who responded codes 1 and 2 in question 18.]

Enter code from list below.

[] 1 Government
[] 2 State-owned enterprise (parastatal)
[] 3 Cooperative
[] 4 Private
[] 5 Other (specify) ____

Form B: Household questionnaire Part 3

Part 3: Fertility information of females aged 15 and over listed in column 2 of part 2

[Questions 1-8 were asked of females age 15 and older]

[1] SI No _

[2] Full name ____

[3] Sl. number in column1 of part 2 _

Fertility information

Number of children born (give number in two digits, like 01, 02... 10, 11, etc. If none, write 00)

[4] How many children have been born alive to the woman?

_ _ Male
_ _ Female

[5] How many of them are living?

_ _ Male
_ _ Female

[6] How many of them have died?

_ _ Male
_ _ Female

Particulars of birth in the last 12 months to women aged 15-49 years
[Questions 7 and 8 were asked of females age 15 to 49]

[7] Any child born alive to the woman during the last 12 months?

Give actual number, like: 1, 2 [...] under the appropriate column. If none, write 00. If no child was born to the woman in the last 12 months, skip to part 4.

_ _ Male
_ _ Female

[8] Did you register the birth of this baby with the civil authority?

[Question 8 was asked of females age 15 to 49 who have given birth during the last 12 months]

Enter code.

[] 1 Yes
[] 2 No

Form B: Household questionnaire Part 4
Part 4: Housing conditions and facilities

Enter code in the box below.

[1] On what basis does the household occupy this dwelling?

Enter code.

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

[2] Main source of light

Enter code.

[] 1 City power
[] 2 Generator
[] 3 Both city power and generator
[] 4 Kerosene
[] 5 Candle
[] 6 Battery
[] 7 None
[] 8 Other (specify) ____

[3] Main cooking fuel

Enter code.

[] 1 Firewood
[] 2 Charcoal
[] 3 Firewood and charcoal
[] 4 Kerosene
[] 5 Liquefied petroleum gas (LPG)
[] 6 LPG and electricity
[] 7 Electricity
[] 8 None
[] 9 Other (specify) ____

[4] Toilet facility within premises

Enter code.

[] 1 Available
[] 2 Not available

If code 1 [available] put type of facility:
[] 1 Connected to sewerage
[] 2 Septic tank
[] 3 Pit latrine
[] 4 Other type of toilet (specify) ____

[5] Main source of drinking water supply

Enter code.

[] 1 Piped water
[] 2 Tube / pipe well
[] 3 Protected dug well
[] 4 Unprotected dug well
[] 5 Spring, river, stream, lake / pond, rain
[] 6 Bought (tanker truck, vender or otherwise bought, bottle bought)
[] 7 Other (specify) ____

[6] Number of rooms occupied by household (exclude kitchen, bathroom, toilet and storeroom)

Enter code.

[] 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

Form B: Household questionnaire Part 5
Part 5: Deaths in households

Deaths in households in the last 12 months: total number of deaths ____

Particulars of the deceased

[1] SI No _

[2] Name of deceased ____

[3] Sex:

Enter code.

[] 1 Male
[] 2 Female

[4] Relationship to head of household [use code given for column 3 of part 2]

Enter code from the list below

[] 1 Head
[] 2 Wife / husband
[] 3 Son / daughter
[] 4 Stepchild
[] 5 Adopted / foster child
[] 6 Father / mother
[] 7 Sibling
[] 8 Grand child
[] 9 Niece / nephew
[] 10 Son / daughter-in-law
[] 11 Brother / sister-in-law
[] 12 Father / mother-in-law
[] 13 Other relative
[] 14 Servant
[] 15 Non-relative including boarder

[5] Age at death _ _

Write the age in total years completed at the time of death.

[] 00 Less than 1 year
[] 01 1 year to less than 2 years
[] 02 2 years to less than 3 years
[] 97 97 years to less than 98 years
[] 98 98 years and older

[6] Did you register the death of this person with the civil authority?

Enter code.

[] 1 Yes
[] 2 No

[7] What was the cause of death?

Enter code located at the bottom of the page.

Illness
[] 1 Fever
[] 2 Diarrhea
[] 3 Cholera
[] 4 Tuberculosis
[] 5 Heart disease
[] 6 Measles
[] 7 Typhoid
[] 8 Dengue fever
[] 9 Cancer
[] 10 Dysentery
[] 11 Malaria
[] 12 Tetanus
[] 13 HIV/AID
[] 14 Sexually transmitted diseases [STDs]
[] 15 Pregnancy complication
[] 16 Delivery complication
[] 17 Abortion
[] 18 Other illness [specify] ____
Accidents
[] 19 Land mine or unexploded bomb injury
[] 20 Road accident
[] 21 Drowning
[] 22 Accident at work [fell from scaffolding, tree etc.]
[] 23 Chemical burns
[] 24 Animals, insect, snakebite
[] 25 Electrical shock
[] 26 Suicide [hanging, poisoning]
[] 27 Death by thunder strike
[] 28 Death by falling tree
[] 29 Suffocation
[] 30 Death by magic spell
[] 31 Poisoning
[] 32 Gun shot
[] 33 Other accident [specify] ____

For women aged 15-49 years who died
[Questions 8 and 9 were asked of females age 15 to 49 who died]

[8] Did the woman die while pregnant, during delivery or within 42 days after giving birth?

[] 1 Yes
[] 2 No

[9] If "Yes" in column 8, did any health professional attend on her before death?

Enter code from list below.

[] 1 Doctor
[] 2 Nurse
[] 3 Midwife
[] 4 Other [specify] ____
[] 5 No attention by health professional