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Royal Government of Cambodia
General Population Census of Cambodia, March 2019

Form A House list
____ Page number
____ Total nsumber of pages for EA

Identification particulars

Province/municipality

Name: ____
Code: _ _

District/Khand/Krong

Name: ____
Code: _ _

Khum/Sangkat

Name: ____
Code: _ _

Phum

Name: ____
Code: _ _

Enumeration area no. _ _

Building/structure and household particulars
[This section is repeated for all respondents]

Line no. ____
Building/structure number _ _ _

Predominant csonstruction (material of building/structure)

3. Wall

[] 1. Bamboo, thatch, grass, reeds
[] 2. Earth
[] 3. Wood or plywood
[] 4. Concrete, brick, stone
[] 5. Galvanized iron, aluminum, other metal sheets
[] 6. Asbestos cement sheets
[] 7. Salvaged, improvised materials
[] 8. Other (specify) ____

4. Roof

[] 1. Bamboo, thatch, grass, reeds
[] 2. Tile
[] 3. Wood, plywood
[] 4. Concrete, brick, stone
[] 5. Galvanized 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

[] 1. Residence
[] 2. Residence and shop
[] 3. Residence and workshop
[] 4. Residence and
[] 5. Parquet, polished wood
[] 6. Mosaic, ceramic tiles
[] 7. Other (specify) ____

7. Household No.: _ _

Particulars of head of household
[Questions 8-9 of this section are specific to the head of household]

8. Name of head of household: ____

9. Sex

[] 1 Male
[] 2 Female

Number of persons usually living in the HH

_ _ 10. Male
_ _ 11. Female
_ _ 12. Total

13. Remarks: ________

Name of enumerator: ____
Signature:____
Date (dd/mm/yyyy): _ _/ _ _/ _ _ _ _

Name of supervisor: ____
Signature: ____
Date (dd/mm/yyyy): _ _/ _ _/ _ _ _ _

Form B household questionnaire part 1

Identification particulars

Province/municipality

Name: ____
Code: _ _

District/Khand/Krong

Name: ____
Code: _ _

Khum/Sangkat

Name: ____
Code: _ _

Phum

Name: ____
Code: _ _

Enumeration area no. _ _
Building no. _ _ _
Household no. _ _
Name of head of household: ____

Population particulars

Statement 1.1: Usual members present on census night
[This section is repeated for all respondents]

Type of household/population:

[] 1. Normal or regular household
[] 2. Institutional household
[] 3. Homeless household
[] 4. Boat population
[] 5. Transient population (specify the location) ____

1. Sl. No. _

2. Name of the person ____

Write the name of the person starting with the head

3. Relationship to head of the household ____

Write in words

4. Sex ____

Write in words

Statement 1.2: Visitors present on census night
[This section is repeated for all respondents]

1. Sl. No. _

2. Name of the person: ____

Write full name of the visitor

3. Relationship to head of the household: ____

Write in words

4. Sex: ____

Write in words

Usual Residence

5.Within Cambodia:
____ 5a. Write name of Khum/Sangkat, Srok/Khand/Krong, Province
____ 5b. Code of location
6. Outside Cambodia:
____ 6a. Write name of country
____ 6b. Code of location

Statement 1.3: Usual members absent on census night
[This section is repeated for all respondents]

1. Sl. No. _

2. Name of the person ____

Write full name

3. Relationship to head of the household ____

Write in words

4. Sex ____

Write in words

5. Age (in completed years): _ _ _

Location on census night

6. Within Cambodia:
____ 6a. Write name of Khum/Sangkat, Srok/Khand/Krong, Province
____ 6b. Code of location
6c. Reason for shifting
[] 1. Employment
[] 2. Business
[] 3. Tourism
[] 4. Education
[] 5. Marriage
[] 6. Medical
[] 7. Other
7. Outside Cambodia:
____ 7a. Write name of the country
____ 7b. Code of location
7c. Reason for shifting
[] 1. Employment
[] 2. Business
[] 3. Tourism
[] 4. Education
[] 5. Marriage
[] 6. Medical
[] 7. Other

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 Statement 1.1 and 1.2

Name of enumerator: ____
Signature:____
Date (dd/mm/yyyy): _ _/ _ _/ _ _ _ _

Name of supervisor: ____
Signature: ____
Date (dd/mm/yyyy): _ _/ _ _/ _ _ _ _

Form B household questionnaire part 2

Individual particulars
[This section except for questions 6 and 8 are to be completed by all persons]

1. Sl. No. _

2. Name of the person ____

Names of usual members present and visitors during the census night, please refer to Statements 1.1 and 1.2 in Part 1

3. Relationship to head of household

[] 1. Head
[] 2. Wife/husband
[] 3. Son/daughter
[] 4. Father/mother
[] 5. Grandchild
[] 6. Other relative
[] 7. Non-relative including boarder

4. Sex

[] 1. Male
[] 2. Female

5. Age in completed years_ _ _

6. Whether living with own mother ____

[This question is for children aged 0-14 years only]

Write serial number of natural mother (if living in this household), for child aged 0-14. If mother not living in this household write '0'.

7. Marital status:

[] 1. Never married
[] 2. Married (i.e. currently married)
[] 3. Widowed
[] 4. Divorced
[] 5. Separated

8. Age at first marriage in completed years _ _ _

[This question is to be answered by all persons except for those who were never married]

Ask only married, widowed, divorced or separated person

9. Mother tongue

[] 1. Khmer
[] 2. Vietnamese
[] 3. Chinese
[] 4. Lao
[] 5. Thai
[] 6. French
[] 7. English
[] 8. Korean
[] 9. 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

10. Religion

[] 1. Buddhism
[] 2. Islam
[] 3. Christianity
[] 4. Other

11. Birthplace

- If in this village, enter code 1,
- If in another village, give name of the Khum/Sangkat of that village and write names of District/Khand/Krong and Province/Khet,
- If outside Cambodia, write name of the country

_____ 11a. Write name of Khum/Sangkat, Srok/Khan/Krong, Khet or country name if another country

_____ 11b. Code of location

12. Previous residence: where has the person been living before

- If always lived in this village, enter 1 and skip to col. 15(a),
- If in another village, give name of the Khum/Sangkat of that village and write name of District/Khand/Krong and Province/Khet,
- If outside Cambodia, write name of the country

____ 12a. Write name of Khum/Sangkat, Srok/Khan/Krong, Khet or country name if another country

____ 12b. Code of location

13. Duration of stay

How long has the person lived in this village _ _

14. Reason for migration

[] 1. Transfer of workplace
[] 2. In search of employment
[] 3. Education
[] 4. Marriage
[] 5. Family moved
[] 6. Lost land/lost home
[] 7. Natural calamities
[] 8. Dislocated due to dam construction
[] 9. Dislocated due to other major or small projects
[] 10. Insecurity
[] 11. Repatriation or return after displacement
[] 12. Orphaned
[] 13. Visiting only
[] 14 Other (specify): ____

[Questions 15-16 are to be completed by all persons]

15. Literacy

15a. Can the person read and write with understanding in Khmer language?
[] 1. Yes
[] 2. No
15b. Can this person read and write with understanding in any other language, if so, which?
[] 1. No other language
[]2. Vietnamese
[] 3. Chinese
[] 4. Lao
[] 5. Thai
[] 6. French
[] 7. English
[] 8. Chaam
[] 9. Other: ____

16. Full-time education

16a. Has the person attended school/education institution?

[] 1. Never
[] 2. Now
[] 3. Past

16b. Currently attending grade

For codes 1 and 3 in column 16a, put dash (-) in 16b.
For code 2 in column 16a, enter the code from the list below.

[] 00. Pre-school/kindergarten
[] 01. Class 1
[] 02. Class 2
[] 03. Class 3
[] 04. Class 4
[] 05. Class 5
[] 06. Class 6
[] 07. Class 7
[] 08. Class 8
[] 09. Class 9
[] 10. Class 10
[] 11. Class 11
[] 12. Class 12
[] 15. Technical/vocational pre-secondary diploma/certificate course
[] 16. Technical/vocational post-secondary diploma/certificate course
[] 17. Undergraduate course
[] 18. Master's degree course
[] 19. Ph.D. course
[] 20. Any other course

16c. What is the highest grade completed?

For code 1 in column 16a, put dash (-) in 16b.
For codes 2 and 3 in column 16a, enter the code from the list below.

[] 00. Pre-school/kindergarten
[] 01. Class 1
[] 02. Class 2
[] 03. Class 3
[] 04. Class 4
[] 05. Class 5
[] 06. Class 6
[] 07. Class 7
[] 08. Class 8
[] 09. Class 9
[] 10. Class 10
[] 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
[] 88. No grade completed

[Question 16d is to be answered by persons who is currently attending or has completed technical/vocational pre-secondary diploma/certificate course or higher grade]

16d. Main subject of study

for codes 15 to 20 in col. 16b or 16c.
Description ____
Code _ _ _
For other codes in col. 16b or 16c. skip to col. 17.

[Questions 17-22 of this section are to be answered by persons aged 5 years and older]

17. Functional difficulty

17.1 Do you have difficulty seeing, even if wearing glasses?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

17.2 Do you have difficulty hearing, even if using a hearing aid?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

17.3 Do you have difficulty walking or climbing step?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

17.4 Do you have difficulty remembering or concentrating?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

17.5 Do you have difficulty with self-care (such as washing all over or dressing)?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

17.6 Do you have difficulty using your usual (customary) language, do you have difficulty speaking, for example understanding or being understood?

[] 1. No -- no difficulty
[] 2. Yes -- some difficulty
[] 3. Yes -- a lot of difficulty
[] 4. Cannot do at all

18. Main activity

Main activity of the person during last year:

[] 1. Employed (fill in cols. 19 to 22)
[] 2. Unemployed (employed any time before, fill in cols. 19 to 22 for last employment)
[] 3. Unemployed (never employed any time before, put dash (-) in cols. 19 to 22)
[] 4. Home maker (put dash (-) in cols. 19 to 22)
[] 5. Student (put dash (-) in cols. 19 to 22)
[] 6. Dependent (put dash (-) in cols. 19 to 22)
[] 7. Rent-receiver, retired or other income recipient (put dash (-) in cols. 19 to 22)
[] 8. Other (put dash (-) in cols. 19 to 22)

19. Occupation

Types of occupation/employment (write the occupation in words):

Name of occupation: ____
Code: _ _ _

20. Employment status/class

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

21. Agriculture, industry, trade, or service

Nature of economic activity (agriculture, industry, trade, or service, write the nature of economic activity in words):

Name of economic activity: _________
Code: _ _ _

22. Sector of employment:

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

Form B household questionnaire part 3

1. Sl. No. _
2. Name of the woman (for women aged 15 and over): ____
3. Sl. No. in column 1 in part 2 _

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

Number of children born
Give number in two digits like 01, 02, 03, ... 10, 11. If none write '00'):

4. How many children have been born alive to the woman?
_ _ 4a. Male
_ _ 4b. Female

5. How many of them are living?
_ _ 5a. Male
_ _ 5b. Female

6. How many of them have died?
_ _ 6a. Male
_ _ 6b. Female

Particulars of birth in the last 12 months to women aged 15-49
[Questions 7-9 of this section are to be completed by women aged 15-49 only]

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 0. If no child was born to the woman in the last 12 months, skip to part 4.

_ _ 7a. Male
_ _ 7b. Female

8. Who assisted her during delivery

[] 1. Doctor
[] 2. Nurse
[] 3. Midwife
[] 4. Traditional birth assistant
[] 5. Other (specify): ____
[] 6. None

9. Did the person register the birth of this baby with the Civil Authority?

[] 1. Yes
[] 2. No

Form B household questionnaire part 4

Housing conditions, amenities and assets possessed by household

1. On what basis does this 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. Type of toilet facility household usually uses

[] 1. None, not using toilet
[] 2. Pour flush (or flush) connected to sewerage
[] 3. Pour flush (or flush) to septic tank or pit
[] 4. Pour flush (or flush) to elsewhere (i.e. not a sewer or pit/tank)
[] 5. Pit latrine with slab
[] 6. Pit latrine without slab or open pit
[] 7. Latrine overhanging field or water (drop in the field, pond, lake, river, sea)
[] 8. Other (specify): ____

5. Share facility with other household

[] 1. Yes
[] 2. No

6. Main source of drinking water supply

[] 1. Piped into dwelling
[] 2. Piped into compound, yard or plot
[] 3. Public tap, standpipe
[] 4. Tube well, borehole
[] 5. Protected well
[] 6. Unprotected well
[] 7. Protected spring
[] 8. Unprotected spring
[] 9. Rainwater collection
[] 10. Tanker-truck
[] 11. Cart with small tank, drum
[] 12. Surface water (river, stream, dam, lake)
[] 13. Bottled water
[] 14. Other (specify): ____

7. Time taken to go there, get water, and come back

[] 1. Water on premises
[] 2. Less than 30 minutes
[] 3. More than 30 minutes
[] 4. Don't know

8. 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 more

9. Availability of separate kitchen within premises

[] 1. Yes
[] 2. No

Particulars of amenities and assets possessed by household
Give the number for each, write '00' if not owned

_ _ 10. Radio/transistor

_ _ 11. Television

_ _ 12. Telephone (fixed)

_ _ 13. Cell phone

_ _ 14. Laptop and desktop computer

_ _ 15. Bicycle

_ _ 16. Motorcycle

_ _ 17. Refrigerator

_ _18. Washer

_ _ 19. Fan

_ _ 20. Air-conditioner

_ _ 21. Car/Van

_ _ 22. Boat

23. Tractor

_ _ 23a. Big tractor
_ _ 23b. Hand tractor (Koyaon)

State whether the household accesses internet

24. At home
[] 1. Yes
[] 2. No
25. Outside home
[] 1. Yes
[] 2. No

Form B household questionnaire part 5: Death in household

Deaths in household in the last 12 months
Total number of deaths _ _

Death particulars
1. Sl. No. _

2. Name of deceased ____

3. Sex

[] 1. Male
[] 2. Female

4. Relationship to head of household

[] 1. Head
[] 2. Wife/husband
[] 3. Son/daughter
[] 4. Father/mother
[] 5. Grandchild
[] 6. Other relative
[] 7. Non-relative including boarder

5. Age at death

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

6. What was the cause of the death

Illness:
[] 1. Fever
[] 2. Diarrhea
[] 3. Tuberculosis
[] 4. Heart disease
[] 5. Dengue fever
[] 6. Malaria
[] 7. Tetanus
[] 8. HIV/AIDS
[] 9. Pregnancy complication
[] 10. Delivery complication
[] 11. Within 42 days after delivery
[] 12. Other illness
Accident:
[] 13. Land mine
[] 14. Road accident
[] 15. Drowning
[] 16. Other accident
[] 17. Don't know

7. Registration of death

Has this death been registered with the Civil Authority?

[] 1. Yes
[] 2. No

For women aged 15-49 who died

8a. Did the woman die while pregnant, during delivery or within 42 days after giving birth?
[] 1. Yes
[] 2. No

8b. If yes in column 8 (a), state where the death took place?
[] 1. Hospital
[] 2. Health center
[] 3. Home
[] 4. Other (specify): ____

8c. If yes in column 8 (a), state who attended on her before death?
[] 1. Doctor
[] 2. Nurse
[] 3. Midwife
[] 4. Traditional birth attendant (TBA)
[] 5. Other (specify): ____
[] 6. None