The information requested is backed by statistical secret and is strictly confidential.
Law 10 of January 22, 2009

Questionnaire Number _ _
Household Number _



I. Location of the dwelling

1. Province ____
2. District ____
3. Judicial Precinct (Corregimiento) ____
4. Segment number ____
5. Locality ____
6. Neighborhood ____
7. Street or Avenue (number or name) ____
8. Building or house (Number or name) ____
9. Room or apartment number ____

For office use

II. Dwelling Information


1. Type of dwelling

1A. Private dwelling

[] 1 Permanent individual
[] 2 Semi-permanent individual
[] 3 Improvised
[] 3 Apartment
[] 5 Room in a tenement house
[] 6 Place not intended for housing, but used as a dwelling
Continue with Chapter III

1B. Without a dwelling

[] 7 Victims of a disaster- Continue with Chapter III
[] 8 Indigents - Continue with Chapter V
[] 9 In the street, control points, seaport, airport - Continue with Chapter V

1C. [] Collective Dwelling - Continue with Chapter V

[Question2 was asked of private dwellings.]
2. Status of the dwelling

2A. Occupied

[] 1 With persons present
[] 2 With persons absent
Continue with the next dwelling

2B. Unoccupied

[] 3 For sale or rent
[] 4 Under repair or construction
[] 5 Seasonal or temporary dwelling
[] 6 Other reason (specify)
Continue with the next dwelling

3. Is your dwelling

[] 1 Mortgaged

Monthly payment in [Balboas] _ _ _ _

[] 2 Rented

Monthly payment in [Balboas] _ _ _ _

[] 3 Owned
[] 4 Ceded
[] 5 Condemned
[] 6 Other, [specify] ____

4. When was this dwelling built?

[] 1 Before 2000
[] 2 Between 2000 and 2005
[] 3 Between 2006 and 2010
[] 4 Not known

5. What is the predominant material in the exterior walls of the building or house?

[] 1 Cement block, brick, stone, concrete
[] 2 Wood (planks, boards)
[] 3 Clay-covered plant fiber (quincha), adobe
[] 4 Metal (zinc, aluminum, among others)
[] 5 Palm leaves, straw, cane or bamboo or sticks
[] 6 Other materials
[] 7 Without walls

6. What is the predominant material in the roof of the building or house?

[] 1 Cement slab
[] 2 Clay tile
[] 3 Other type of tiles ([Asbestos-cement brands] tejalit, panalit, techolit, among others)
[] 4 Metal (zinc, aluminum, among others)
[] 5 Wood
[] 6 Palm leaves, straw or sticks
[] 7 Other materials

7. What is the predominant material in the floor of this dwelling?

[] 1 Mosaic or tiles, marble and parquet
[] 2 Pavement (concrete)
[] 3 Brick
[] 4 Wood
[] 5 Dirt
[] 6 Other materials (cane, sticks, discarded materials, among others)

8. How many rooms does this dwelling have?
(Do not include kitchen, laundry and bathrooms)

Number of rooms _ _
8A. Of these, how many are only bedrooms? _ _

9. What is primary source of drinking water?

[] 1 Public aqueduct of the IDAAN
[] 2 Public aqueduct of the community
[] 3 Private aqueduct
Answers 1-3, continue with question 10
[] 4 Covered spring well
[] 5 Uncovered spring well
[] 6 Rainwater
[] 7 Superficial well
[] 8 River, stream, or lake
[] 9 Cistern truck
[] 10 Bottled water
[] 11 Other (specify) ____
For answers 4-11, continue with question 13

10. Are the installations for drinking water inside the dwelling?

[] 1 Yes
[] 2 No

11. How many days a week is drinking water delivered?

During the dry season? _
During the rainy season? _

12. Approximately, how many hours per day is drinking water delivered?

During the dry season? _ _
During the rainy season? _ _

13. Does this dwelling have toilet facilities

[] 1 Pit or latrine
[] 2 Connected to a sewage system
[] 3 Connected to a septic tank
Answers 1-3, continue with question 15
[] 4 No sanitary service

14. What is the most frequently used place for this dwelling to deposit human waste?

[] 1 Scrubland
[] 2 River or stream
[] 3 Sea
[] 4 Uses the sanitary service of the neighbor
[] 5 Other (specify)
Continue with question 16.

15. The use of the toilet facilities is

[] 1 For the exclusive use of the dwelling
[] 2 Shared with other dwellings

16. What type of lighting does the dwelling have?

[] 1 Electric from the electrical company

How much do you usually pay per month?

In Balboas _ _ _ _
[] 9997 Does not pay
[] 9998 Included in rent

[] 2 Electricity from the community

How much do you usually pay per month?

In Balboas _ _ _ _
[] 9997 Does not pay
[] 9998 Included in rent

[] 3 Provides own electricity (generator)
[] 4 Kerosene or diesel
[] 5 Gas (kerosene)
[] 6 Candles
[] 7 Solar panel
[] 8 Other (specify) ____

17. How does this dwelling dispose of trash?

[] 1 Public collection truck
[] 2 Private collection truck
[] 3 Incineration or burning
[] 4 Empty lot
[] 5 Burial
[] 6 River, stream, lake or sea
[] 7 Other (specify) ____

18. What type of fuel is most frequently used for cooking in the dwelling?

[] 1 Gas (natural gas)
[] 2 Firewood
[] 3 Electricity
[] 4 Kerosene
[] 5 Coal (charcoal)
[] 6 Does not cook

19. Is part of this dwelling used for any economic activity?
(Work such as seamstress, beauty salon, workshop, kiosk or store, sale of fried foods, among others)

[] 1 Yes

[Specify the activity _ _ _ _]

[] 2 No

20. Do the persons who live in this dwelling use a second dwelling for vacations or weekends, whether owned, rented, or ceded?

[] 1 Yes
Continue
[] 2 No
Continue with question 21.
20A. Where is this second dwelling located?
(If more than one is used, refer to the one that is most used)

[] 0001 In this same place
In another locality? Specify ____

Judicial Precinct (Corregimiento) ____
District ____
Province ____

Continue with question 21.
Province _ _
District _ _
Judicial District _ _
A. _ _
[] 9998 In another country?
Continue with question 21.

Number of households in the dwelling


21. How many household inhabit this dwelling?
Consider a household made up of persons who share a common pot and one budget for expenses.

Households _ _

III. Information about the household


22. Does this household have

a. Stove

[] 1 Yes
[] 2 No

b. Refrigerator

[] 1 Yes
[] 2 No

c. Washing machine

[] 1 Yes
[] 2 No

d. Sewing machine

[] 1 Yes
[] 2 No

e. Residential phone

[] 1 Yes
[] 2 No

f. Radio/stereo

[] 1 Yes

How many _ _

[] 2 No

g. Electric fan

[] 1 Yes

How many _ _

[] 2 No

h. Air conditioning

[] 1 Yes

How many _ _

[] 2 No

i. Cellular phone

[] 1 Yes

How many _ _

[] 2 No

j. Automobile

[] 1 Yes

How many _ _

[] 2 No

k. Television

[] 1 Yes

How many _ _
Connected to tv via cable/satellite?
[] 1 Yes
[] 2 No

[] 2 No

l. Computer?

[] 1 Yes

How many _ _
Do you have an internet connection?
[] 1 Yes
[] 2 No

[] 2 No

23. Here or in another place, any person living in this household

a. Planted any type of grain (rice, corn, beans, or other) yucca, name, otoe, vegetables, cane, or other crops in 2009?

[] 1 Yes
[] 2 No

b. Has plants or fruit trees or harvestable wood trees, or pastures?

[] 1 Yes
[] 2 No

c. Has medicinal plants or ornamental plants for commercial purposes?

[] 1 Yes
[] 2 No

d. Has bovine cattle, pigs, horses, mares, mules, donkeys, asses, sheep, goats, or calves?

[] 1 Yes
[] 2 No

e. Has breeding stock of chickens, ducks, geese, turkeys, Cornish hens or bees?

[] 1 Yes
[] 2 No

International Emigration


24. In the past 10 years, has any member of this household gone to live permanently in another country?

1. Yes

1. Name of the person ____
2. Sex

[] 1 Male
[] 2 Female

3. Age when the person left _ _ _
4. Year in which the person left _ _ _ _
5. What country did the person go to? ____

2. No -- Continue with Chapter IV. List of occupants of the household.

IV. List of occupants of the household
Tell me the names and last names of all of the persons who slept last night in the household, beginning with the head of household (male or female) and continue in the following order: spouse, unmarried children (male and female) from eldest to youngest, married children (male and female) with their spouses and children, other relatives, non-relatives and household servants.
Also include those who did not sleep here but did not sleep elsewhere.
[There is space to fill in 8 names]

1. Person number


2. Name and last name (person number 1 on the list should be the male or female head of household
________
3. Sex4. Does any member of this household have a physical or mental disability?5. Does any indigenous person live here?6. Is any person in this household considered to be black or of African descent?

If there are more than eight persons in the household, use one or more additional questionnaires and continue the list of occupants of the household.

When you complete the interview of the household, review the questionnaire and verify that the number of enumerated persons list in the questionnaire is equal to those registered in Chapter IV. List of occupants of the household. Then, you add up the persons by sex and note the numbers in the corresponding boxes.

Observations regarding the information about the dwelling, the household, and the list of occupants of the household. ____
Information about person 01
Name and last name ____
V. General characteristics

For all individuals in the household


[Questions 1 - 9 were asked of all individuals.]



Head of household (male or female)
[For the head of household]

[] 1 [Head of household]
Nuclear family number _ _

1. What is your relationship to the head of the household?

[] 2 Spouse of the head of household
[] 3 Son or daughter
[] 4 Son-in-law or daughter-in-law
[] 5 Grandson/granddaughter or great-grandson/great-granddaughter
[] 6 Father or mother of the head of household
[] 7 Father-in-law or mother-in-law of the head of household
[] 8 Other relative (specify)
[] 9 Domestic service
[] 10 Non-related
Nuclear family number _ _

[The remaining of the form for person number 02 is identical to that for person number 01, up to question 9]

2. Sex

[] 1 Male
[] 2 Female

3. How old is the person in completed years?

Age _ _ _
What is the person's birth date?

Day _ _
Month _ _
Year _ _ _ _

4. Do you currently receive social security benefits as

[] 1 Direct insured
[] 2 Beneficiary
[] 3 Retired due to old age
[] 4 Pensioner due to accident or illness
[] 5 Retirement or pension from another country
[] 6 None

5. What is your current marital status?

[] 1 Consensual union
[] 2 Married, but separated
[] 3 Consensual union, but separated
[] 4 Married
[] 5 Divorced
[] 6 Widowed
[] 7 Single
[] 8 Under the age of 15 years old?

6. Health limitations

a. Even with hearing aids for loss of hearing, do you have trouble hearing?

[] 1 Yes
[] 2 No

b. Even using eyeglasses, do you have difficulty seeing?

[] 1 Yes
[] 2 No

c. Do you have any permanent difficulty for walking or getting around?

[] 1 Yes
[] 2 No

d. Do you have any permanent difficulty for using your arms and/or hands?

[] 1 Yes
[] 2 No

e. Do you have any permanent difficulty for speaking or communicating?

[] 1 Yes
[] 2 No

f. Do you have any permanent learning difficulty?

[] 1 Yes
[] 2 No

Ask this question if, on the list of occupants of the dwelling (Chapter IV), the name of the person who has the circle number 1 marked (Yes) in question 4 (disability). In the case to the contrary, mark circle 8, None.

7. What type of physical or mental disability do you have?

[] 1 Blindness
[] 2 Deafness
[] 3 Mental retardation
[] 4 Cerebral paralysis
[] 5 Physical deficiency
[] 6 Mental problems
[] 7 Other (Specify)
[] 8 None.

Ask this question if, on the list of occupants of the dwelling (Chapter IV), the name of the person has the circle number 1 marked (Yes) in question 5 (Indigenous). In the contrary case, mark circle 10, None.
8. To which indigenous group do you belong?

[] 1 Kuna
[] 2 Ngäbe
[] 3 Buglé
[] 4 Naso/Teribe
[] 5 Bokata
[] 6 Emberá
[] 7 Wounaan
[] 8 Bri Bri
[] 9 Other (Specify) ____
[] 10 None

Ask this question if, on the list of occupants of the dwelling (Chapter IV), the name of the person has the circle number 1 marked (Yes) in question 6 (Black or African Descent). In the contrary case, mark circle 5, None.
9. Do you consider yourself to be

[] 1 Colonial black
[] 2 Antillean black
[] 3 Black
[] 4 Other (specify) ____
[] 5 None

[Questions 10 to 12A were asked to all persons]



10. Where did your mother live when you were born

[] 0001 In this same place
Continue with question 11.
In another populated place?

Specify ____
District ____
Province or indigenous district ____
Province _ _ District _ _ A _

Continue with question 11

In another country?

Specify ____
Country _ _ _
10A. In which period did you arrive in Panama

[] 1 Before May, 2000
[] 2 Between May, 2000 and April 2005
[] 3 Between May 2005 and today

11. Where you live permanently?

[] 0001 In this same place
Continue with question 12.
In another populated place?

Specify ____
District ____
Province or indigenous district ____
Province _ _ District _ _ A _

Continue with question 12
[] 9998 In another country
Conclude the interview with this person.

12. Where did you live before coming to live where you live permanently?

[] 0001 In this same place
Continue with question 13.
In another populated place?

Specify ____
District ____
Province or indigenous district ____
Province _ _ District _ _ A _

Continue with question 12A
In another country?

Specify ____
Country _ _ _
12A. In which period did you arrive in the place where you live permanently

[] 1 Before May, 2000
[] 2 Between May, 2000 and April 2005
[] 3 Between May 2005 and today

VI. Educational characteristics

For individuals 4 years of age and older.


[Questions 13 and 14 were asked to individuals 4 years old and older]


If the person is less than 4 years old, continue with question 28.

13. Do you currently attend school?

[] 1 Yes
[] 2 No

14. What is the highest level and grade or school year that you have completed?

[] 01 No grade
[] 02 Preschool
[] 03 Special education
1 _ Elementary
For any response above, continue with question 15
2 _ Vocational
3 _ Secondary
4 _ Higher, non-university
5 _ Higher, university
6 _ Specialization (graduate)
7 _ Master's
8 _ Doctorate
Continue with question 16.

[Questions 15 and 16 were asked to individuals 10 years of age and older]


For individuals 10 years of age and older.

If the person is less than 10 years old, continue with question 28.


15. Are you able to read and write?
(Mark yes only when the person knows how to do both.)

[] 1 Yes -- Continue with question 16.
[] 2 No -- Continue with Chapter VII. Economic Characteristics, question 17.

16. What diploma or degree do you have?

Specify ____
[] 0001 None

VII. Economic Characteristics

For individuals 10 years of age and older.

If the person is less than 10 years old, continue with question 28.

[Questions 17 to 27 were asked to individuals 10 years old and older]



17. Did you work last week?

[] 1 Yes -- Continue with question 23.
[] 2 No -- Continue with question 18.

18. Do you have a job from which you were temporarily absent last week?

[] 1 Yes -- Continue with question 23.
[] 2 No -- Continue with question 19.

19. Last week, did you do any work for which you received any money, such as: sell lottery tickets or newspapers, make food; wash, iron, or sew clothing; wash cars, shine shoes, cut grass, weave, make hats, among others?

[] 1 Yes -- Continue with question 23.
[] 2 No -- Continue with question 20.

20. Did you look for work last week?

[] 1 Yes -- Continue with question 23.
[] 2 No -- Continue with question 21.

21. Did you look for work last month?

[] 1 Yes -- Continue with question 23.
[] 2 No -- Continue with question 22.

22. What was the reason for not looking for work last week?

[] 1 You do work for fixed periods of time
[] 2 You already found a job
[] 3 You looked previously and are awaiting a response
[] 4 You are tired of looking for a job
Answers 1-4, continue with question 23.
[] 5 You are retired or pensioned for old age
[] 6 You are pensioned (for accident or illness)
[] 7 You are a student only
[] 8 You are a housewife or household worker
[] 9 You have a permanent disability from work
[] 10 Advanced age (70 years old and more)
[] 11 Other inactive people. Specify ____
Answers 5- 11, continue with question 28.

23. What occupation, job, or work did you do last week or the last time that you worked? If you have more than one job, note the occupation of your primary job. Consider the primary job to be the one that generates the greatest income.

Primary occupation ____
[] 9998 Never worked - Continue with question 28.

24. Where do you work or did you work the last time?
(Note the name of the establishment, business, or institution; if you work on the street, in your house, in the house of a relative, or agricultural farm, among others, note what the informant declares.

25. What is the primary business of the company, establishment or business where you work or worked the last time?

____
Principal activity of the business or establishment _ _ _ _

26. You work or worked last as

[] 1 Government employee
[] 2 Employee of a non-profit organization
[] 3 Employee of a cooperative
[] 4 Employee of a private business
[] 5 Employed as a domestic employee
[] 6 Employed by the Canal Commission or Defense Sites
Answers 1-6, continue with question 27.
[] 7 Independent or self-employed
[] 8 Owner or Employer
[] 9 Member of a Production Cooperative
[] 10 Family worker
Answers 7-10, continue with question 28.

27. Are you or were you a ___ employee?

[] 1 Permanent
[] 2 Contracted for a specific job
[] 3 On a fixed contract
[] 4 On an open-ended contract
[] 5 Without a written contract

For all of the members of the household


[Questions 28 and 28A were asked to all household members]



28. What was your income last month for _____? How much (in balboas)?

a. Salary or gross income? _ _ _ _ _
b. Thirteenth-month payment? _ _ _ _ _
c. Income for independent work or self-employment? _ _ _ _ _
d. Retirement or old-age pension? _ _ _ _ _
e. Pension (due to accident, illness, survival benefits or other)? _ _ _ _ _
f. Assistance from institutions or other person(s) who do not live with you?

1) Food allowance? _ _ _ _ _
2) Money? _ _ _ _ _
3) Other? (specify) ____

g. Leases, rents, interests, or benefits? _ _ _ _ _
h. Scholarships? _ _ _ _ _
i. Agricultural sales? _ _ _ _ _
j. Other income? _ _ _ _ _

28A. Income:

[] 1 Has income
[] 2 Has no income
[] 3 Not declared

VIII. Fertility and mortality characteristics

For women who are 12 years old or more


[Questions 29 and 30 were asked to women 12 years old or more]



29. How many children have you had that were born alive?

Total number of children _ _

Continue with question 30.

[] None

Continue with the next person.

30. Of these, how many are alive?

Total number of live children _ _

For women who are between 12 and 49 years old, who have declared to have children born alive.


[Questions 31 and 32 were asked to women 12 to 49 years old, who have declared to have children born alive.]



31. Of your children born alive, were any born within the past twelve months?

[] 1 Yes

Date of birth

Day _ _
Month _ _
Year _ _ _ _

Continue with question 32.
[] 2 No - Continue with the next person.

32. Is this boy or girl still alive?

[] 1 Yes
[] 2 No