Steering Committee for Census of Population and Housing

Census of Population and Housing, 1 March 2005

A. Identification

Province _ _
District _ _
Village _ _ _
EA number _ _
Household number _ _ _
Form number within household _ _ _

[] If the household continues on next page, tick here

[] If living in a collective household, tick here

B. For all persons
[Questions 1- 10 were asked of all persons]

1. Who was a member of this household?

List names and surnames of all persons who were member of the household ____

2. Who is [the respondent]'s relationship to head of household?

[] 1 Head of household
[] 2 Husband / wife
[] 3 Son / daughter
[] 4 Parents
[] 5 Son in-law / daughter in-law / relatives
[] 6 Other

3. Sex

[] 1 Male
[] 2 Female

4. How old was [the respondent] at his/her last birthday? _ _ _

Enter age in completed years. ('0' for children less than 1 year.)

5. Where was [the respondent] born?

Enter district, province or country code from code list 5. If born in the same place, please tick cross in box.

[] Same place
[] 1 Cambodia
[] 2 China
[] 3 Burma
[] 4 Thailand
[] 5 Vietnam
[] 6 Other Asian country
[] 7 Europe
[] 8 Africa
[] 9 America
[] 10 Australia
[] 11 Other countries
[] 9999 Don't know

6. Where was [the respondent] living at last census March 1995?

7. What is [the respondent]'s citizenship?

Enter code from code list no. 7. If "Lao", please tick cross in box.

[] Lao
[] 1 Cambodia
[] 2 China
[] 3 Burma
[] 4 Thailand
[] 5 Vietnam
[] 6 Other Asian country
[] 7 Europe
[] 8 Africa
[] 9 America
[] 10 Australia
[] 11 Other countries
[] 99 Don't know

8. What is [the respondent]'s ethnic origin?

Enter code from code list no. 8. If "Lao", please tick cross in box.

[] 1 Laos
[] 2 Thai
[] 3 Phuthai
[] 4 Leu
[] 5 Nguan
[] 6 Yung
[] 7 Sairk
[] 8 Thaineau
[] 9 Keummeu
[] 10 Prai
[] 11 Singmoon
[] 12 Phong
[] 13 Thein
[] 14 Adoo
[] 15 Bid
[] 16 Lamed
[] 17 Samtao
[] 18 Katang
[] 19 Makong
[] 20 Tri
[] 21 Yuroo
[] 22 Treang
[] 23 Toay
[] 24 Yerh
[] 25 Brao
[] 26 Katu
[] 27 Hahak
[] 28 Oy
[] 29 Grieng
[] 30 Cheng
[] 31 Sdang
[] 32 Shuay
[] 33 Ngahearn
[] 34 Lavy
[] 35 Pako
[] 36 Kamer
[] 37 Toum
[] 38 Guan
[] 39 Moy
[] 40 Kree
[] 41 Akha
[] 42 Singsiri
[] 43 Lahoo
[] 44 Sila
[] 45 Hayee
[] 46 Lolo
[] 47 Hor
[] 48 Mong
[] 49 Ilmearn
[] 50 Other
[] 51 No Answer

9. What is [the respondent]'s marital status?

[] 1 Never married
[] 2 Married
[] 3 Divorced/ separated
[] 4 Widowed
[] 9 No answer

10. What is [the respondent]'s religion?

[] 1 Buddhist
[] 2 Christian
[] 3 Bahai
[] 4 Islam
[] 5 Other
[] 9 No answer

C. For 6 years and above
[Questions 11-14 were asked of persons 6 years and older]

11. Can [the respondent] read and write Lao?

[] 1 Yes
[] 2 No
[] 6 Less than 6 years
[] 9 No answer

12. Has [the respondent] ever attended school?

[] 1 Never been (Go to section D.)
[] 2 At school
[] 3 Left school
[] 4 No answer (Go to section D.)

13. What is [the respondent]'s highest level of education?

Enter education code.

[] 1 No education
[] 11 Grade 1
[] 12 Grade 2
[] 13 Grade 3
[] 14 Grade 4
[] 15 Grade 5
[] 16 Grade 6
[] 21 Lower secondary 1
[] 22 Lower secondary 2
[] 23 Lower secondary 3
[] 31 Upper secondary 1
[] 32 Upper secondary 2
[] 33 Upper secondary 3
[] 99 Don't know

14. What is [the respondent]'s highest level of vocational education?

Enter code.

[] 1 First level
[] 2 Middle level
[] 3 High / university
[] 4 Post graduate level
[] 5 Other
[] 9 Don't know

D. For persons age 10 years and above
[Questions 15-17 were asked of persons age 10 years and older.]

15. What was [the respondent]'s main occupation the last 12 months?

Enter code.

[] Under 10
[] 1 Government employee
[] 2 Parastatal employee
[] 3 Private employee
[] 4 State enterprise employee
[] 5 Employer
[] 6 Own account worker
[] 7 Unpaid family worker
[] 8 Unemployed
[] 9 Student
[] 10 Household duties
[] 11 Retired/ sick/ too old
[] 99 Don't know

16. What was [the respondent]'s main activity in occupation during the last 12 months?

[For those who answered code 1-7 in Question 1.]

[] 1 Farmer
[] 2 Fisherman
[] 3 Farmer mainly livestock
[] 4 Mixing farming
[] 9 Other (specify) ____

17. In what industrial sector was [the respondent] mainly working during the last 12 months?

[For code 1 to 7 in Question 15.]

In agriculture, please tick in box. If nonagriculture, please specify.

[] Agriculture
[] Other

Specify ____

[] Don't know

E. For women, aged 15 to 49 years
Ask woman that are present at enumeration
[Questions 18-20 were asked of present women age 15 to 49].

18. Have you give any live birth?

[] 1 Yes
[] 2 No
[] 9 No answer

[In Question 18] If no (2) or (9): continue with next woman. If yes (1): How many children born alive to you...

Were with you on census night?

_ Male
_ Female

Were elsewhere than with you on census night?

_ Male
_Female

Have died?

_Male
_Female

19. How old were you when you gave your first live birth?

Age _ _

20. Number of live births last 12 months

_ Male
_Female

F. Death in household

21. Did any death occur in the household last 12 months?

[] 1 Yes
[] 2 No

Was there a deceased male or female?

[If yes (1) in Question 21]
[] 1 Male
[] 2 Female

How old was the deceased?

Age _ _ _

Did she die while pregnant, while giving birth, or within 42 days after giving birth?

[For women 15-49 years and for deaths other than in accidents]

[] Yes
[] No

G. Last 12 months any member of household moved in or moved out

22. Moved into this household

[] 1 Yes
[] 2 No

Serial number _

Moved into this household?

[] 1 Same province
[] 2 Other province
[] 3 Capital
[] 4 Other country

23. Moved out of this household?

[] 1 Yes
[] 2 No

Sex

[] 1 Male
[] 2 Female

Age _ _ _

Moved out of this household?

[] 1 Same province
[] 2 Other province
[] 3 Capital
[] 4 Other country

H. Number of disabilities in household

24. Is there any disable person in this household?

[] 1 Yes
[] 2 No

Serial number _

Type of disability

[] 1 Visually handicapped
[] 2 Dead/dumb
[] 3 Arm/leg handicapped
[] 4 Multiple handicapped
[] 5 Other

Cause of disability

[] 1 Since birth
[] 2 War accident
[] 3 Accident
[] 4 Drug addicted
[] 5 Diseases
[] 6 Other

I. Housing characteristics

25. What is the tenure status of the household?

[] Owner
[] Tenant
[] Lodger
[] Tied accommodation
[] Other

26-28. Which type of building materials are used for the dwelling unit?

26. Roof

[] Tile or sipax
[] Zinc
[] Wood
[] Bamboo
[] Grass
[] Other

27. Wall

[] Brick or concrete
[] Wood
[] Bamboo
[] Other

28. Floor

[] Ceramic/ tile
[] Concrete
[] Wood
[] Bamboo
[] Other

29. Is this dwelling unit electrified?

[] Yes (own meter)
[] Yes (shared meter)
[] Yes (own generator)
[] Yes (car battery)
[] No

30. What is the total area of the dwelling unit?

Total area in meters squared _ _ _

What is the actual living area in meters squared?

Total living area in meters squared _ _ _

31. Water for drinking and cooking

What is the household's main source of water for drinking and cooking? [For each of the sources of water, a distance to that water source is selected.]

[] 1 Pipe water
[] 2 Well / borehole, protected
[] 3 Well / borehole, unprotected
[] 4 River / stream / dam
[] 5 Mountain source
[] 6 Rain water
[] 7 Other

Distance to water source [For each of the different sources of water.]

[] On premises
[] Less than 500 m
[] Between 500 m and 1 km
[] More than 1 km

32. What type of toilet facility is mainly used by this household?

[] Modern toilet
[] Normal toilet
[] Other
[] None

33. What is the household's main source of energy for cooking?

[] Electricity
[] Paraffin / fuel
[] Coal
[] Charcoal
[] Sawdust
[] Gas
[] Other

34. Does the household operate any agriculture land?

[] 1 Yes
[] 2 No (Go to Question 35)

What is the size of this agriculture land?

Hectar _ _, _ _

J. Total population

35. Total population

_ _ _ Male
_ _ _ Female
_ _ _ Total

Notes ________
____ Interviewer
____Date
____Supervisor
____Date

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