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National Census Steering Committee
The Fourth Population and Housing Census, 1 March 2015

Questionnaire Booklet Code _ _ _ _ _ _
(Enter questionnaire booklet codes by code that Lao Statistics Bureau given)

Identification

Province _ _
District _ _
Village _ _
EA.No _ _
Book. No _ _

____ Province name
____ District name
____ Village name

Comments ________

At village ____
Date ____/____/____
Stamp and signature of village's head ____

Household number _ _

Household type

[] 1. Individual HH
[] 2. Collective HH

Population

____ Male
____ Female
____ Total

Total

____ Male
____ Female
____ Total

Village infrastructure information:

1. Located in the municipality of district/province

[] 1. Yes
[] 2. No

2. At least 70% of HH in the village have electricity

[] 1. Yes
[] 2. No

3. At least 70% of HH in the village have water supply

[] 1. Yes
[] 2. No

4. Road accessibility

[] 1. Yes
[] 2. No

5. Permanent market

[] 1. Yes
[] 2. No

6. Health center/hospital

[] 1. Yes
[] 2. No

7. Does this village have primary school?

[] 1. Yes, completed school (all 5 levels)
[] 2. Yes, incomplete school (less than 5 levels)
[] 3. No primary school

Village type

[] 1. Urban
[] 2. Rural with road
[] 3. Rural without road

Field work quality checking

1. Supervisor on district level

____ Date
____ Name
____ Signature

2. Supervisor on province level

____ Date
____ Name
____ Signature

3. Supervisor on central level

____ Date
____ Name
____ Signature

[next page]

A. Identification

Province _ _
District _ _
Village _ _ _
EA. No. _ _
Building No. _ _ _ _
Household No. _ _ _

Household type

[] 1. Individual household
[] 2. Collective household

Village type

[] 1. Urban
[] 2. Rural with road
[] 3. Rural without road

Form No. within HH _ _

If HH continuous on next page put an ''X'' in this box []

B. For all persons in the household

Q1. Person ID _

Q2. Name and surname of household members ____
List names of all persons who are members of the HH. Start from the head of household.

Q3. Relationship to the head of household

[] 1. Head of household
[] 2. Husband/wife
[] 3. Son
[] 4. Son-in-law
[] 5. Parent/parent-in-law
[] 6. Grandchild
[] 7. Relative
[] 8. Non-relative

Q4. Sex

[] 1. Male
[] 2. Female

Q5. Age

Enter age in completed years _ _ _
For children less than 12 months, enter "000"

Q6. Marital status

[] 1. Never married
[] 2. Married
[] 3. Divorced/separated
[] 4. Widowed
[] 5. Stay-together

Q7. Citizenship

[] 1. Lao (Tick box 1 below and go to Q8)
[] 2. Other (Enter the country code in box 2 and go to Q9)

Enter the country code:
[] 01. Cambodia
[] 02. China
[] 03. Myanmar
[] 04. Thailand
[] 05. Vietnam
[] 06. Other Asian
[] 07. Europe
[] 08. Africa
[] 09. Americas
[] 10. Australia/Oceania
[] 11. Other

Q8. Ethnic origin
[This question was asked of the person whose citizenship is Lao.]

Enter the code from the list provided.

Only Lao citizens need to answer this question.

Code list:
[] 01. Lao
[] 02. Tai
[] 03. Phouthay
[] 04. Lue
[] 05. Ngoaun
[] 06. Yang
[] 07. Xaek
[] 08. Thaneua
[] 09. Khmou
[] 10. Pray
[] 11. Xingmoun
[] 12. Phong
[] 13. Thaen
[] 14. Oedou
[] 15. Bid
[] 16. Lamed
[] 17. Samtao
[] 18. Katang
[] 19. Makong
[] 20. Tri
[] 21. Yrou
[] 22. Triang
[] 23. Ta-oy
[] 24. Yae
[] 25. Brao
[] 26. Katu
[] 27. Harak
[] 28. Oy
[] 29. Griang
[] 30. Cheng
[] 31. Sadang
[] 32. Xuay
[] 33. Nhaheun
[] 34. Lavy
[] 35. Pacoh
[] 36. Khmer
[] 37. Toum
[] 38. Guan
[] 39. Moy
[] 40. Kree
[] 41. Hmong
[] 42. Ewmien
[] 43. Akha
[] 44. Pounoy
[] 45. Lahou
[] 46. Syla
[] 47. Hayi
[] 48. Lolo
[] 49. Hor
[] 50. Other
[] 51. No

Q9. Religion

[] 1. Buddhist
[] 2. Christian
[] 3. Bahai
[] 4. Islam
[] 5. Other
[] 6. No-religion

Q10. Place of birth

[] 1. Same district as living now
(Mark ''X'' in box 1 below)
[] 2. Different district as living now _ _
(Enter province and district codes in box 2 below)

_ _ Province
_ _ District
[] 3. Another country _ _ _ _
(Enter the country code in box 3 below)

Code list:
[] 01. Cambodia
[] 02. China
[] 03. Myanmar
[] 04. Thailand
[] 05. Vietnam
[] 06. Other Asian
[] 07. Europe
[] 08. Africa
[] 09. Americas
[] 10. Australia/Oceania
[] 11. Other

Do you have any difficulty with the following activities?

Q11. Seeing
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q12. Hearing
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q13. Walking/climbing stairs
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q14. Remember/concentrate
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q15. Washing/dressing
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q16. Communicating
[] 1. No difficulty
[] 2. Yes, some difficulty
[] 3. Yes, a lot of difficulty
[] 4. Cannot do at all

Q17. Cause of main difficulty

(For persons with any difficulty from Q11 to Q16)

[] 1. Since birth
[] 2. War
[] 3. Accident
[] 4. UXO
[] 5. Disease
[] 6. Other

C. For persons 6 and above
[Questions Q18-Q21 are asked of persons age 6 and above only]

Q18. Can you read and write with understanding?

[] 1. Yes, Lao
[] 2. Yes, other
[] 3. Not at all

Q19. Have you ever attended school?

[] 1. Never (Go to Q22)
[] 2. Yes, study now
[] 3. Yes, left

Q20. What is your highest level of education achieved? _ _

(Enter the code from the code list in the next page)

Cost list:
[] 00. No grade
[] 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
[] 24. Lower secondary 4
[] 32. Upper secondary 1
[] 33. Upper secondary 2
[] 34. Upper secondary 3
[] 41. Vocation education first level
[] 42. Vocation education middle level
[] 43. Vocation education high level
[] 44. Graduate - degree holder
[] 45. Post graduate - master's degree
[] 46. Higher than post graduate
[] 99. Don't know

Q21. If code 41-46 in Q20, what is the main subject of study? _ _

(For code 41 to 46 in Q20)

Code list:
[] 14. Teacher training and education science
[] 21. Arts
[] 22. Humanities
[] 31. Social sciences
[] 32. Journalism and information
[] 34. Business and administration
[] 38. Law
[] 42. Life science
[] 44. Physical science
[] 46. Mathematics and statistics
[] 48. Computer
[] 52. Engineering and trade
[] 54. Manufacturing and processing
[] 58. Architecture and building
[] 62. Agriculture, forestry and fishing
[] 64. Veterinary
[] 72. Health
[] 76. Social services
[] 81. Personal services
[] 84. Transportation services
[] 85. Environmental protection
[] 86. Security services

D. For persons 10 and above
[Questions Q22-Q26 are asked of persons age 10 and above only]

Q22. Place of living at last census in March 2005

[] 1. Same district as living now
(Mark ''X'' in box 1 below)
[] 2. Different district as living now
(Enter province and district codes in box 2 below)

_ _ Province
_ _ District
[] 3. Another country
(Enter the country code in box 3 below)

Code list:
[] 01. Cambodia
[] 02. China
[] 03. Myanmar
[] 04. Thailand
[] 05. Vietnam
[] 06. Other Asian
[] 07. Europe
[] 08. Africa
[] 09. Americas
[] 10. Australia/Oceania
[] 11. Other

Q23. Main reason for moving here

[] 1. Transfer of work place
[] 2. In search of employment
[] 3. Business
[] 4. Education
[] 5. Marriage
[] 6. Family moved
[] 7. Village move
[] 8. Other

Q24. What is your main activity in the last 12 months?

(Enter the code from the code list in next page)

Code list:
[] 01. Government employee
[] 02. Private employee
[] 03. State enterprise employee
[] 04. Employer
[] 05. Own account worker
[] 06. Unpaid family worker
[] 07. International organization and NGO
[] 08. Unemployed
[] 09. Student
[] 10. Household duties
[] 11. Other

[Questions Q25-Q26 are asked of persons who answered codes 01-07 in Q24]

Q25. What is your main occupation in the last 12 months?

Please describe in detail in what your main occupation in the past 12 months ________

Q26. In what industry where you are working

Input the code provided in the back page of the cover _ _

[next page]

E. For women aged 15-49 years old (Directly ask female)

Q27. Person ID from Q1 _ _

Q28. Have you ever given any live birth?

[] 1. Yes
[] 2. No

(Continue to ask next female)

Number of children ever born alive

Q29. How many children are living currently with you?
_ _ Male
_ _ Female

Q30. How many children are living elsewhere?
_ _ Male
_ _ Female

Q31. How many children have died?
_ _ Male
_ _ Female

Q32. How old were you when you gave your first live birth?

(Enter age in completed years)
_ _

Particulars of last live births

Q33. Date of last live birth
_ _ Month
_ _ Year

Q34. Sex of last live birth
[] 1. Male
[] 2. Female

Q35. Is the children still alive?
[] 1. Yes
[] 2. No

F. Deaths in the last 12 months

Q36. Any deaths in the last 12 months

[] 1. Yes
[] 2. No (Go to Q40)

Q37. Sex of deceased

[] 1. Male
[] 2. Female

Q38. Age of deceased

Enter age in completed years _ _ _

Q39. Did she die while pregnant, while giving birth or within 42 days after giving birth?

For women 15-49 years.

[] 1. Yes
[] 2. No

G. Moved in during past 12 months

Q40. Moved into the HH?

[] 1. Yes
[] 2. No (Go to Q44)

Q41. Person ID from Q1 _ _

Q42. Moved from:

[] 1. Same district as living now
(Mark ''X'' in box 1)
[] 2. Different district as living now
(Enter province and district codes in box 2)

_ _ Province
_ _ District
[] 3. Another country
(Enter the country code in box 3 below)

Code list:
[] 01. Cambodia
[] 02. China
[] 03. Myanmar
[] 04. Thailand
[] 05. Vietnam
[] 06. Other Asian
[] 07. Europe
[] 08. Africa
[] 09. Americas
[] 10. Australia/Oceania
[] 11. Other

Q43. Main reason for moving in

[] 1. Transfer of workplace
[] 2. In search of employment
[] 3. Business
[] 4. Education
[] 5. Marriage
[] 6. Family moved
[] 7. Village move
[] 8. Other

H. Moved out during past 12 months

Q44. Moved out of this HH?

[] 1. Yes
[] 2. No (Got to Q49)

Q45. Sex

[] 1. Male
[] 2. Female

Q46. Age

Enter age in completed years _ _ _

Q47. Moved to:

[] 1. Same district as living now
(Mark ''X'' in box 1)
[] 2. Different district as living now
(Enter province and district codes in box 2)

_ _ Province
_ _ District
[] 3. Another country
(Enter the country code in box 3 below)

Code list:
[] 01. Cambodia
[] 02. China
[] 03. Myanmar
[] 04. Thailand
[] 05. Vietnam
[] 06. Other Asian
[] 07. Europe
[] 08. Africa
[] 09. Americas
[] 10. Australia/Oceania
[] 11. Other

Q48. Main reason for moving out

[] 1. Transfer of workplace
[] 2. In search of employment
[] 3. Business
[] 4. Education
[] 5. Marriage
[] 6. Family moved
[] 7. Village move
[] 8. Other

I. Dwelling characteristics

Q49. What is the tenure status of the household?

[] 1. Owner
[] 2. Rent - pay rent
[] 3. Rent - no pay rent
[] 4. Rent - employer provide free
[] 5. Other (e.g. homeless)

What are the main building materials used for this dwelling?

Q50. Roof
[] 1. Tile/sipax/concrete
[] 2. Zinc
[] 3. Wood
[] 4. Bamboo
[] 5. Grass
[] 6. Other

Q51. Walls
[] 1. Brick/concrete
[] 2. Wood
[] 3. Bamboo
[] 4. Other

Q52. Floor
[] 1. Ceramic/tile
[] 2. Concrete
[] 3. Wood
[] 4. Bamboo
[] 5. Other

Q53. Does this dwelling have electricity?

[] 1. Yes (own meter)
[] 2. Yes (share meter)
[] 3. Yes (own generator)
[] 4. No - use batteries
[] 5. No electric

Q54. What is the total area of the unit this household occupy in square metres? _ _ _
(Refer to records where available. Give a best guess if unsure)

Q55. How many rooms are there in this dwelling?

Include: bedroom, living room, kitchen, dining room
Exclude: toilet, bathroom, laundry

Number of rooms _ _ _

Q56.What is this household's main source of drinking water?

[] 1. Piped water
[] 2. Well/borehole protected
[] 3. Well/borehole unprotected
[] 4. River/stream/dam
[] 5. Mountain source
[] 6. Rain water
[] 7. Bottle/can water
[] 8. Tank
[] 9. Other

Q57. How far do you travel to this water source?

[] 1. On premises
[] 2. Less than 200m
[] 3. 200m to 500m
[] 4. 500m to 1km
[] 5. More than 1km

Q58. What is the type of toilet facility mainly used by this household?

[] 1. Flush/pour flush
[] 2. Pit latrine ventilated
[] 3. Pit latrine other
[] 4. Composting toilet
[] 5. Bucket
[] 6. Hanging toilet/hanging latrine
[] 7. Other

Q59. What is he household's main source of energy for cooking?

[] 1. Electricity
[] 2. Paraffin/fuel
[] 3. Wood
[] 4. Coal
[] 5. Charcoal
[] 6. Sawdust
[] 7. Gas
[] 8. Other

Q60. What assets does this household own in working order?

Vehicles

1. Tractor
[] Yes
[] No

2. Car/van
[] Yes
[] No

3. Mother bike
[] Yes
[] No

4. Bicycle
[] Yes
[] No

5. Boat
[] Yes
[] No

Household items

6. Radio
[] Yes
[] No

7. Television
[] Yes
[] No

8. Telephone fixed
[] Yes
[] No

9. Cell phone
[] Yes
[] No

10. Computer
[] Yes
[] No

11. Washing machine
[] Yes
[] No

12. Air-conditioner
[] Yes
[] No

13. Fan
[] Yes
[] No

14. Fridge/freezer
[] Yes
[] No

Other

15. Agriculture-land
[] Yes
[] No

J. Total persons

Q61. Male _ _ _

Q62. Female _ _ _

Q63. Total _ _ _

Notes ________

Enumerator ____
Date ____/____/____

Supervisor ____
Date ____/____/____