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Republic of Liberia
Ministry of Planning and Economic Affairs
Form PH-3 Long Form

1974 Census of Population

Confidential: The questionnaire is required by the Government of Liberia for the purposes of planning for the future as well as appraising the present needs of the Country. All information herein is accorded confidential treatment and cannot be used for the purposes of taxation, investigation or regulation. No person on this form will be mentioned by name, only totals will be shown.

a. City, Town or other place name ____
b. Street address if available ____
c. Structure number ____
d. Household serial number ____

1. Name

What is the name of the head of this household?
Name of persons who usually live here.
Any babies or old people you did not list?
Name of persons staying here with no usual place of residence elsewhere.
Name of persons not usual residents but who have been staying here more than two months.
How many persons staying here less than two months have a usual place of residence elsewhere?
(List all persons in order shown in relationship to head column. If absent, enter "X".)
Are there any other persons who are usually here that have not been mentioned? If yes, list them.

2. Relationship to head
List persons in following order:

HEAD. First.
Wife with unmarried children.
Other wives and their children (number each wife)
Married children of head.
Grandchildren of head.
Other related persons.
Other nonrelated persons.

3. Sex

[] 1 Male
[] 2 Female

4. Age
Last birth date ____

5. Marital status
Ask all persons over ten years

[] 1 Never married
[] 2 Married
[] 3 Widowed
[] 4 Divorced/ Separated

6. Country of birth
Country if outside of Liberia ____

7. Length of residence
Number of years person lived in this country. If always, enter "25." If less than one year, enter "00".
_____

8. Citizen of Liberia

[] 1 Yes
[] 2 No

9. Tribe
Write name of tribe. If no tribe enter "00"
____

Ask all persons over the age of five years

10. Literacy
Can person read and write English?

[] 1 Yes
[] 2 No

11. School attendance
Is person presently attending school?

[] 1 Yes
[] 2 No

12. Highest grade completed
What was the highest grade completed? ___________
If none enter "00"

Ask all women over age 10 years

13. Number of children born
Ask all women over age 14 years regardless of marital status.

__ At home
__ Away from home
__ Died
__ Ever born
__ Surviving

14. Children born in past year
____

Ask all persons over age 10 years

15. Economic activity
What was person doing most during past 12 months? (If the person reported as anything but working, skip columns on occupation, industry and work status.)

[] 1 Working
[] 2 Keeping house
[] 3 Student
[] 4 Retired
[] 5 Other

16. Usual occupation
If person working, what type of work did they do?
Example: Rice farmer, auto mechanic
CODE: ____

17. Business or industry
What kind of business or industry did person work in?
Example: Iron mine, Rice farm
CODE: ____

18. Work status:
Was person paid employee?
Was person employer?
Was person self-employed?
Was person unpaid family worker?

[] 1 Employee
[] 2 Employer
[] 3 Self-employed
[] 4 Unpaid family worker

Ask all households

H-1 Type of housing unit

[] 1 Conventional -- permanent
[] 2 Conventional -- semi-permanent
[] 3 Temporary

H-2 Is housing unit owned by someone living in it of is it rented?

[] 1 Owned or being bought
[] 2 Rented for cash
[] 3 Rent free or other arrangement
If rented, what is monthly rent?

H-3 construction materials of outerwalls

__ Stone, concrete cement block
__ Wood boards
__ Mud and mat
__ Reed, bamboo, grass
__ Galvanized iron
__ Other

H-4

__ Number of households in this structure
__ Number of rooms in this household
__ Number of persons in the household
__ Number of persons in household under age 14 years

H-5 Utilities available in housing unit

Inside pipe water
[] 1 Yes
[] 2 No
Electricity
[] 1 Yes
[] 2 No
Inside flush toilet
[] 1 Yes
[] 2 No
Is kitchen shared with other units?
[] 1 Yes
[] 2 No
Is toilet shared with other units?
[] 1 Yes
[] 2 No

H-6
Number of persons who died in this household in past year ____

H-7 Availability of radio in housing unit

[] 1 Yes
[] 2 No

H-8 What is the monthly income of the head of this household?

[] 1 Under $50 per month
[] 2 $50 to $100 per month
[] 3 $100 to $150 per month
[] 4 $150 to $200 per month
[] 5 $200 to $250 per month
[] 6 $250 to $300 per month
[] 7 $300 to $350 per month
[] 8 $350 to $400 per month
[] 9 Over $400 per month