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Royal Government of Cambodia
Cambodia Inter-Censal Population Survey, 2013

Strictly confidential

Form A: House list

Appendix I

Identification particulars

Khet / Municipality

[] Name
[] Code

Srok / Khand / Krong

[] Name
[] Code

Khum / Sangkat

[] Name
[] Code

Phum / Mondol

[] Name
[] Code

Sample EA number

[] Name
[] Code

Number of households in EA _ _ _

Building / structure and household particulars

1. Line number _

[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 planks
[] 3 Concrete / 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
[] 3 Residence and workshop
[] 4 Residence and any other establishment (specify)

7. Household number _ _

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 _ _ _

Strictly confidential Form B Household Questionnaire Part 1

Form B: Household questionnaire

Form B: Part 1

Identification particulars

____ _ _ Khet / Municipality
____ _ _ Srok / Khand / Krong
____ _ _ Khum / Sangkat
____ _ _ Phum / Mondol
____ _ _ Enumeration area number.
____ _ _ Building number.
____ _ _ Household number

Name of head of household ____
S. No. of household selected (copy from column14 of form A) _ _ _
Number of form B used for the household _

Population particulars

Statement 1.1: Usual members present on survey night

1. SI. number _

2. Full name ____

3. Relationship to head of household (write in words) ____

4. Sex

(Enter code)

[] 1 Male
[] 2 Female

Statement 1.2: Visitors present on survey night

1. SI. Number _

2. Full name ____

3. Relationship to head of household (write in words) ____

4. Sex

(Enter code)

[] 1 Male
[] 2 Female

5. Usual residence: Within Cambodia

Give name of district and write name of province within brackets.

____ District
____ Province

6. Usual residence: Outside Cambodia

Give name of country ____

Statement 1.3: Usual members absent on survey night

1. SI. number _

2. Full name ____

3. Relationship to head of household (write in words) ____

4. Sex

(Enter code)

[] 1 Male
[] 2 Female

5. Age _ _

6. Location on survey night: Within Cambodia

Give name of district and write name of province within brackets.

____ District
____ Province

7. Location on survey night: 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

Part 2: Individual particulars

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

1. SI. number _

2. Full name of the person ____

Names of usual members present and visitors (please refer to statements 1.1 and 1.2 in part 1)

3. Relationship to head of household

Enter code from the list below.

[] 1 Head
[] 2 Wife / husband
[] 3 Son / daughter
[] 4 Step child
[] 5Adopted / 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

6. Mother

Is your mother (i.e. natural mother) alive?

[] 1 Yes (for person aged 15 and over)
[] 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 (i.e. currently 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 only married, widowed, divorced or separated person)

For all persons
[Questions 10 to 25 were asked of all persons]

10. Mother tongue

Enter code from the list below

[] 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
[] 17 Phnong
[] 18 Proav
[] 19 Tumpoon
[] 20 Stieng
[] 21 Ro Ong
[] 22 Kraol
[] 23 Raadear
[] 24 Thmoon
[] 25 Mel
[] 26 Khogn
[] 27 Por
[] 28 Suoy
[] 29 Other (specify) ____


11. Religion

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


12. Place of birth of the person

[] 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 year to less than 2 years
[] 02 2 years to less 3 years
[] 03 3 years to less than 4 years
[] 04 4 years to less than 5 years
[] 10 10 years to less than 11 years
[] 20 20 years to less than 21 years
[] 97 97 years to less than 98 years
[] 98 98 years and over

15. Reason for migration

Give the reason for the change of residence, if the present residence is different from the previous residence (enter code from the list below).

[] 01 Transfer of work place
[] 02 In search of employment
[] 03 Education
[] 04 Marriage
[] 05 Family moved
[] 06 Lost land / lost home
[] 07 Natural calamities
[] 08 Insecurity
[] 09 Repatriation or return after displacement
[] 10 Orphaned
[] 11 Visiting only
[] 12 Other (specify) ____

16. Literacy

a. Can the person read and write with understanding the Khmer language?
(Enter code)

[] 1 Yes
[] 2 No

b. Can this person read and write with understanding in any language? If so, which language?
(Enter the code from the list below)

[] 1 No other language
[] 2 Vietnamese
[] 3 Chinese
[] 4 Lao
[] 5 Thai
[] 6 French
[] 7 English
[] 8 Cham
[] 9 Other (specify) ____

17. Full-time education

a. Has the person ever attended school/ educational institution?
(Enter code)

[] 1 Never
[] 2 Now
[] 3 In the past

b. Currently attending grade for code 2 of column 17(a)
[Question 17b was asked of persons currently attending school]

(Enter the code from the list below)

For code 1 ["never"] and code 3 ["in the past"] in col. 17(a), put a dash (-)
For code 2 ["now"] in col. 17(a), code from list below [not all the possible responses are represented]:

[] 00 Pre-school/kindergarten
[] 01 Grade 1
[] 02 Grade 2
[] 11 Class 11
[] 12 Class 12
[] 15 Technical / vocational pre-secondary diploma / certificate
[] 16 Technical / vocational post-secondary diploma / certificate
[] 17 Undergraduate course
[] 18 Post graduate course
[] 19 Post-master degree course
[] 20 Any other course (specify) ____

c. Highest grade completed
[Question 17c was asked of persons who ever attended school/educational institution]

(Enter the code from the list below)

For code 1 ["never"] in col. 17(a), put a dash (-)
For code 2 ["now"] and code 3 ["in the past"] in col. 17(a), code from list below [not all the possible responses are represented]:

[] 00. Pre-school / kindergarten
[] 01 Grade 1
[] 02 Grade 2
[] 11 Class 11
[] 12 Class 12
[] 13 Lower secondary diploma / certificate
[] 14 Upper secondary diploma / certificate / baccalaureate
[] 15 Technical / vocational pre-secondary diploma / certificate
[] 16 Technical / vocational post-secondary diploma / certificate
[] 17 Graduate degree
[] 18 Master's degree
[] 19 Ph.D. degree
[] 20 Any other diploma / degree completed (specify) ____
[] 88 No grade completed

d. Main subject of study
[Question 17d was asked of persons who ever attended school / educational institution and answered codes 15 to 20 in questions 17(b) or 17(c)]

For codes 15 to 20 in columns [questions] 17(b) or 17(c):
Description ____
Code _ _ _
For other codes [0 to 14] in columns 17(b), (c) skip to column 18

18. Physical/mental disability, if any:

If the person is physically/mentally disabled, give the appropriate code number from the list below. Otherwise enter 0.

Type of disability

[] 1 In seeing
[] 2 In speech
[] 3 In hearing
[] 4 In movement
[] 5 Mental retardation
[] 6 Mental illness
[] 7 Any other (specify) ____
[] 8 Multiple disability (specify by code) ____

19. Main activity: main activity of the person during last year

(Enter the code from the list below)

[] 1 Employed (fill in columns 20 to 24)
[] 2 Unemployed (employed any time before) (fill in cols. 20 to 24 for last employment)

[For codes 1 or 2, continue to questions 20 to 24 and response according to present or last employment]

[] 3 Unemployed (never employed any time before)
[] 4 Home maker
[] 5 Student
[] 6 Dependent
[] 7 Rent-receiver, retired or other income recipient
[] 8 Other (specify) ____

(For codes 3, 4, 5, 6, 7 and 8 put dash (-) in columns 20 to 24)

[Question 20 to 24 were asked of persons who have ever worked, as per question 19]

20. Employment period _ _

Number of months employed in the last 12 months

21. Occupation ____ _ _ _

Name of occupation

22. Employment status:

Employment status / class

(Enter the code from the list below)

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

23. Industry, trade or service: ____ _ _ _

Nature of industry, trade or service

24. Sector of employment

Sector in which [the respondent] is employed

(Enter the code from the list below)

[] 1 Government
[] 2 State-owned enterprise
[] 3 Cambodian enterprise (private)
[] 4 Foreign enterprise
[] 5 Non-profit institution
[] 6 Household sector
[] 7 Embassies, international institutions and foreign aid and development agencies
[] 8 Other (specify) ____

25. Secondary economic activity (for all codes 1 through 8 in column 19)

In terms of contribution to income or subsistence, what was the second most important economic activity of this individual over the last year?

(Enter code from the list below)

[] 01 None

Farming (growing crops)
[] 02 Unpaid employment (self-employed or employed in family enterprise)
[] 03 Paid employment (wage laborer)
Livestock farming
[] 04 Unpaid employment (self-employed or employed in family enterprise)
[] 05 Paid employment (wage laborer)
Other activities
[] 06 Fishing
[] 07 Other household-based production or services
[] 08 Construction
[] 09 Wholesale or retail trade
[] 10. Transport
[] 11. Other paid employment (services like teaching, cooking, childcare, medical, etc.)

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

[Questions 1-7 were asked of females age 15 and older]

1. SI. number _

2. Full name of woman ____

3. Sl. number in column1 of part 2 _

4. Age of woman at the time of birth of first child_ _

Give the age in completed years

Fertility information

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

5. How many children have been born alive to the woman?

_ _ Male
_ _ Female

6. How many of them are living?

_ _ Male
_ _ Female

7. How many of them have died?

_ _ Male
_ _ Female

Particulars of birth in the last 12 months from women aged 15-49 years
[Questions 8-10 were asked of females age 15 to 49]

8. 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 0. If no child was born to the woman in the last 12 months, put dash (-) in columns 9 and 10.

_ _ Male
_ _ Female

[Questions 9-10 were asked of females age 15 to 49 who have given birth during the last 12 months]

9. State who assisted her during the delivery

Enter code from the list below.

[] 1 Doctor
[] 2 Nurse
[] 3 Midwife
[] 4 Traditional birth attendant (TBA)
[] 5 Other
[] 6 None

10. Did she get the birth of this child registered with the civil authority?

Enter code.

[] 1 Yes
[] 2 No

Part 4: Death in household

Deaths in household in the last 12 months _ _

Total number of deaths

Particulars of deceased

1. SI. number _

2. Full 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
[] 4Step child
[] 5Adopted / 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 [Not all the possible responses are represented]

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 over

6. What was the cause of death?

(Enter code from the list below)

Illness:
[] 01 Fever
[] 02 Diarrhea
[] 03 Tuberculosis
[] 04 Heart disease
[] 05 Dengue fever
[] 06 Malaria
[] 07 Tetanus
[] 08 HIV / AIDS
[] 09 Pregnancy complication
[] 10 Delivery complication
[] 11 Other illness (specify) ____
Accident
[] 12 Land mine
[] 13 Road accident
[] 14 Drowning
[] 15 Other accident (specify) ____
Not known
[] 16 Don't know

7. Has this death been registered with the civil authority?

Enter code

[] 1 Yes
[] 2 No

For women aged 15-49 years who died
[Questions 8(a), (b) and (c) were asked of females age 15 to 49 who died]

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

[] 1 Yes
[] 2 No [continue to part 5 of the questionnaire]

If "yes" in column 8(a)
[Question 8(b) and (c) were asked of females ages 15 to 49 who died while pregnant, during delivery, or within 42 days after giving birth, as per question 8(a)]

8b. State where the death took place:

(Enter code from the list below)

[] 1 Hospital
[] 2 Health center
[] 3 Home
[] 4 Other

8c. State who attended on her before death:

Enter code from the list below.

[] 1 Doctor
[] 2 Nurse
[] 3 Midwife
[] 4 Traditional birth attendant (TBA)
[] 5 Other (specify) ____
[] 6 None

Part 5: 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 Other (specify) ____

3. Main cooking fuel

Enter code.

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

4. Toilet facility within premises

Enter code.

[] 1 Not available

If available, give one of the codes 2 to 5:

[] 2 Connected to sewerage
[] 3 Septic tank
[] 4 Pit latrine
[] 5 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 Rain
[] 6 Spring, river, stream, lake / pond
[] 7 Bought
[] 8 Other (specify) ____

6. Location of drinking water source:

Enter code.

[] 1 Within the premises
[] 2 Near the premises
[] 3 Away

7. 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

8. Availability of separate kitchen within premises

Enter code.

[] 1 Yes
[] 2 No

Information on ownership of some facilities by the household (under each item, write "00" in the square if not available or give the actual number, if available)

9. Radio/transistor _ _

10. Television _ _

11. Telephone (desk phone) _ _

12. Cell phone _ _

13. Personal computer _ _

14. Bicycle _ _

15. Motorcycle _ _

16. Refrigerator _ _

17. Washing machine _ _

18. Air-Conditioner _ _

19. Fan _ _

20. Car/van _ _

21. Boat _ _

22. Tractor

_ _ a. Big tractor
_ _ b. Hand tractor (koyaon)

State whether the household accesses the internet

23. Internet: At home

(Enter code)

[] 1 Yes
[] 2 No

24. Internet: Outside the home

(Enter code)

[] 1 Yes
[] 2 No

25. Internet: Home and outside home

(Enter code)

[] 1 Yes
[] 2 No