The information solicited is confidential
Decree-law No. 7, February 25th, 1960

Republic of Panama
Comptroller General
Directorate of Statistics and Census

Form No. ____

Seventh National Population Census and Third Housing Census
May 10th, 1970

Family Form

For office use:

____ Type of settlement
____ Segment number
____ Form number
____ Locality or block

I. Location of the Dwelling

____ 1. Segment number
____ 2. Province
____ 3. District
____ 4. Judicial Precinct (Corregimiento)
____ 5. Locality
____ 6. Street or Avenue (number or name)
____ 7. Number and name of the building or establishment
____ 8. Room or apartment number

For the cities of Panamá and Colón, note in addition:

____ 9. Block number

II. Dwelling information

1. Type of dwelling

Private house

[] 1 Permanent or semi-permanent
[] 2 Improvised

[] 3 Apartment
[] 4 Room in a tenement (casa de vecindad)
[] 5 Place not intended for habitation but used as a dwelling
[] 6 Collective (group quarters)

2. Condition of the dwelling (occupancy)

[] 1 With inhabitants present
[] 2 With inhabitants absent
Unoccupied:

[] 3 For rent
[] 4 For sale
[] 5 Under repair
[] 6 Summer home
[] 7 Other reason

Ask questions 3 to 14 for those dwellings with occupants present classified in one of the boxes 1, 2, 3 and 4 of question number 1, type of dwelling.

3. Rooms in this dwelling:

How many rooms does it have? ____

Of these, how may are bedrooms? ____

Does it have a separate kitchen?

[] 1 Yes
[] 2 No

4. Ownership and rent:

[] 1 Owned
[] 2 Rented: Monthly rent B/. ____
[] 3 Ceded

5. Predominant material in the exterior walls of the building:

[] 1 Cement block, brick, stone
[] 2 Wood (planks, boards)
[] 3 Clay-covered plant fiber (quincha), adobe
[] 4 Straw, palm leaves, cane, sticks
[] 5 Other material or without walls

6. Material in the roof of the building:

[] 1 Cement
[] 2 Tile
[] 3 Asbestos-cement
[] 4 Metal (zinc, aluminum, etc)
[] 5 Treated [coated] wood
[] 6 Straw or palm leaves
[] 7 Other

7. Material in the floor of the dwelling:

[] 1 Pavement (concrete, tile, brick, etc.)
[] 2 Wood
[] 3 Earth
[] 4 Other

8. Source of drinking water:

Public aqueduct (piped system):

[] 1 Inside the dwelling
[] 2 Outside the dwelling
[] 3 Private aqueduct (piped system)

Sanitary Well:

[] 4 Public
[] 5 Private
[] 6 Uncovered spring
[] 7 Rainwater
[] 8 Surface (superficial) well
[] 9 River or stream

9. Sewer facilities:

Private:

[] 1 Connected to sewer
[] 2 Connected to septic tank
[] 3 Pit or latrine

Shared use:

[] 4 Connected to sewer
[] 5 Connected to septic tank
[] 6 Pit or latrine

[] 7 Without toilet facilities

10. Availability of bathroom:

Private:

[] 1 Supplied with water by pipe
[] 2 Supplied with water by another method

Shared:

[] 3 Supplied with water by pipe
[] 4 Supplied with water by another method

[] 5 Without bathroom

11. Lighting:

[] 1 Electric
[] 2 Gas
[] 3 Kerosene
[] 4 Other

12. Fuel used for cooking:

[] 1 Electricity
[] 2 Gas
[] 3 Kerosene
[] 4 Charcoal or wood
[] 5 No cooking

13. Domestic appliances:

Sewing machine

[] 1 Yes
[] 2 No

Refrigerator

[] 1 Yes
[] 2 No

Television

[] 1 Yes
[] 2 No

Radio

[] 1 Yes
[] 2 No

14. Was this dwelling built after 1960?

[] Yes

If yes, write the year ____

[] No

Comments: ________

[The following sections A, B, C, D, and E, consist of a form with two columns, for the answers referring to the first and second individuals. Except for question 1, the questions and the response options are identical for both individuals.]

A. General Characteristics

1. What is your name and surname?

Write the name of each person who slept in this dwelling the night of May 9th and of those who passed the night elsewhere, if they were not housed in another dwelling. Do not forget to include infants.

____

2. What relationship or relation do you have with the head of the household?

Mark the appropriate box.

1st Person

[] 1 Head

2nd Person

[] 2 Spouse or partner
[] 3 Son or daughter
Other (specify) ____

3. Sex:

Mark the appropriate box.

[] 1 Male
[] 2 Female

4. How old are you?

Write the age in years. If under 1 year of age, write 00. If the age is unknown, write "doesn't know."

Years ____

5. What is your marital status?

(For those under 15 years of age, do not ask the question and mark the box "minor".) For those who state "single," before marking that box, ask if the person was ever married or in a consensual union. If the response is negative mark "single"; if affirmative mark the appropriate box under "separated."

Consensual union: one who lives in a marital union without being legally married. Single: one who has never married nor lived in a consensual union. Married: one who has legally married and lives in this state. Widowed: a person whose spouse or partner has died and who has not remarried nor lives in a consensual union. Divorced: a person who is legally separated and who has not remarried nor lives in a consensual union. Separated: one who lives separately from the spouse or partner.

[] 1 Consensual union
[] 2 Single
[] 3 Married
[] 4 Divorced
[] 5 Widowed

Separated:

[] 6 From a marriage
[] 7 From a consensual union

6. Where were you born?

Mark the box "here" if born in this same place of enumeration. If born in another locality, write the name of the locality (town or city) and the district to which it belongs. If born in the Panama Canal Zone, write "Canal Zone" in the space designated for "locality." If born abroad, write only the name of the country.

[] Here

Locality ____
District ____

[] In another country ____

7. Where do you live permanently?

This refers to the locality (town or city) where the person habitually resides. If the same as the place of enumeration, write the box "here" and leave the other spaces in this question blank. If living in another part of the country write the name of the place, judicial precinct (corregimiento), and district. If living abroad, write the name of the country and do not ask question 8.

[] Here

Locality ____
Judicial Precinct (corregimiento) ____
District ____

[] In another country ____

8. Where did you live in May of 1965?

If on this date the person lived in the same place as the place of enumeration, mark the box "here" and do not fill in the rest of the blanks in this question. If the person lived in a different part of the country write the name o the place, judicial precinct (corregimiento) and district. If the person lived abroad, write the name of the country.

[] Here

Locality ____
Judicial Precinct (corregimiento) ____
District ____

[] In another country ____

B. Educational Characteristics

[Questions 9 to 12 are asked for those who 6 years old or older]

9. What is the highest grade or school year you have completed?

Write the number on the corresponding line according to the type of schooling. If no grade was completed, mark the box 04.

[] 1 Primary ____
[] 2 Secondary ____
[] 3 University ____
[] 4 None

10. Can you read and write?

Mark the appropriate box. When the person has completed at least the third grade of primary school, do not ask this question and mark the box "yes."

[] 1 Yes
[] 2 No

11. What diploma, certificate or degree do you have?

Write the degree (diploma or certificate) that the person has obtained and the school where it was received. If the person possesses multiple degrees, write the highest one. If the person has no degree, mark the box "none."

Degree (title) ____
School ____
[] None

12. Do you currently attend school?

(Only for those between 6 and 40 years of age)

Write the number in the appropriate space according to the type of schooling, year or grade the person is currently attending. If attending another, non-regular type of schooling, mark the box 04. If not attending any school, mark the box 05.

[] 1 Primary ____
[] 2 Secondary ____
[] 3 University ____
[] 4 Other type of school
[] 5 Not currently attending

C. Economic Characteristics

[Questions 13 - 18 were asked of persons 10 years of age and older.]

13. Did you have any job or employment last week?

If the answer is yes, mark the box "worked." If the answer is no, ask, "then, what did you do (how did you spend your time) last week?" For one who "did not work, but looked for a job," ask if the person had been employed before and mark box 2 or 3 as appropriate.
Remember that a homemaker is one who engages exclusively in household duties in her own home without receiving remuneration, and who does not attend school.
Retiree, pensioner and rentier: one who has income without working. Other condition: student, disabled, children and other inactive individuals.

[] 1 Worked
Did not work but looked for work

[] 2 Worked before
[] 3 Never worked

[] 4 Homemaker
[] 5 Retiree, pensioner, rentier
[] 6 Other condition

14. What occupation, position or job did you carry out last week?

For those who worked, write clearly the principal occupation, position or job. For those who did not work, but had worked before and looked for work, write the last occupation, position or job. For those who looked for work for the first time, write "new worker" and do not ask question 15 to 18.

Occupation ____

15. Were you paid for your work in money or in kind by a person, institution or company?

(Only for those who worked and those who had been employed before and looked for work.)

If the answer is yes, ask "where did you work" and mark the box 1, 2, or 3 as appropriate. If the answer is no, keep in mind the following: If self-employed without any paid employees or subordinates, mark box 4. If an owner or boss, mark box 5. If working for any family member, without remuneration, mark box 6.

Employee

[] 1 Of the government
[] 2 Of a private company
[] 3 Canal Zone

[] 4 Own-account worker
[] 5 Boss (owner)
[] 6 Family worker

16. Where did you work?

For government employees, write the name of the department and ministry or institution of employment. For employees of private companies, write the name and the principal activity of the company or establishment. For employees in the Panama Canal Zone, write the name of the company, office, section, division or department of employment. For a boss, own-account worker, or family worker also ask "what is the principal activity in your job?"

Name of the company or institution ____
Principal activity ____

17. What wage or salary do you earn?

Write the amount derived and the form of established payment (hourly, daily, weekly, or monthly). If the person also receives income from commissions, pension or retirement, write the amount.

Salary B/s. ____ per ____
Commission B/s. ____ per ____
Pension B/s. ____ per month

18. How many hours did you work last week?

(Only for those who worked) Write the number of hours worked during the last week in the job performed.

Hours ____

D. Social Security

[Questions 19 to 20 are asked of those who are 10 years old or older.]

19. Have you ever paid Social Security?

Mark the appropriate box.

[] 1 Yes
[] 2 No

20. Did you pay Social Security last month?

Mark the appropriate box.

[] 1 Yes
[] 2 No

E. Fertility

[Questions 21 to 22 are asked of women 15 years old or older.]

21. How may children born alive have you had?

(For all women 15 years of age and older.}

If she has never had children, write 00.

Children ____

22. Of these, how many were born in the last 12 months?

(Only for women 15 to 50 years of age.)

Write the number of children declared by the informant. If she has had no children in the indicated period, write 0.

Children ____

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