National Institute for Statistics and Computing
National Census: 9th Population Census and 6th Housing Census

Census Seal

Confidential information protected by Executive Order Number 043-2001- PCM on Statistical Confidentiality.

Dwelling number _ _ _

[] 1 Additional Form

First section: Localization of the dwelling and number of households

[Questions 1-14]

A. Geographic Location
1. Department ____

2. Province ____

3. District ____

4. Populated Area [centro poblado] ____

B. Census Location
Urban Area:

5. Zone Number ____

6. Section Number ____

7. Urban Census Area [A.E.U.] Number ____

8. Block Number ____

9. Building Number ____
Rural Area

10. Section Number _ _ _

11. Rural Census Area [A.E.R.] Number

First _ _ _
Last _ _ _

12. Address

Type of road (Circle one number only):

[] 1 Avenue
[] 2 Urban Road [Jirón]
[] 3 Street
[] 4 Urban Passage Road [Pasaje]
[] 5 Highway
[] 6 Extension [Prolongación]
[] 7 Other

Name of road ____
Door Number ____
Apartment Building [block] ____
Interior ____
Floor ____
Block ____
Lot ____
Kilometer ____

C. Number of Households

Begin the interview with the head of household

13. Sir (Madam), how many groups of people [households] cook separately in this dwelling?

Total number of households ____

14. Household number ____

Second section: Dwelling characteristics and services
[Questions 1-9]

Look at the dwelling and determine the type of occupation and its status

1. Type of dwelling (circle only one number)

1A. Individual Dwelling

[] 1 Detached house
[] 2 Apartment in a building
[] 3 Attached independent units [vivienda en quinta]
[] 4 Dwelling in a tenement [Vivienda en casa de vecindad (callejón, solar o corralón)]
[] 5 Shack or cabin
[] 6 Improvised dwelling
[] 7 Premise not intended for human habitation
[] 8 Other

1B. Collective Dwelling

[] 9 Hotel, hostel, lodging
[] 10 Boarding house
[] 11 Hospital, clinic
[] 12 Jail, rehabilitation center
[] 13 Retirement home
[] 14 Children's village, orphanage, etc.
[] 15 Other

1C. Other Type

[] 16 In the street, homeless people, [at] border checkpoint stations, ports, airports, etc.

If you circled any number between 9 and 16, go to the fifth section.

2. Dwelling Status (circle one number only)

2a. Occupied

[] 1 People present
[] 2 People absent
[] 3 Occasional use

2b. Unoccupied

[] 4 For sale or rent
[] 5 Under construction or repair
[] 6 Abandoned/closed
[] 7 Other

If you circled any number between 2 and 7 conclude the interview and continue with the next dwelling, otherwise continue with question 3.

3. What is the dwellings predominant building material?

3A. The predominant material of the exterior walls is (read each option and circle only one number):

[] 1 Brick or cement block
[] 2 Adobe or mud wall [tapia]
[] 3 Wood (palm [pona], tornillo tree, etc.)
[] 4 Cane sticks with clay [quincha o caña con barro]
[] 5 Woven straw or reeds [estera]
[] 6 Stone with clay
[] 7 Limed or cemented stone or ashlar [piedra o sillar con cal o cemento]
[] 8 Other material

3B. The predominant building material of the floors is (read each option and circle only one number):

[] 1 Earth
[] 2 Cement
[] 3 Paving stones [losetas], terrazzo, ceramic tile or similar
[] 4 Parquet or polished wood
[] 5 Wood (palm [pona], tornillo tree, etc.)
[] 6 Asphalt membrane, vinyl or similar
[] 7 Other

4. How is the dwelling supplied with water? (Read each option and circle only one number)

[] 1 Public network within the dwelling (potable water)
[] 2 Public network outside the dwelling but within the building (potable water)
[] 3 Public tap (potable water)
[] 4 Water tanker or similar
[] 5 Well
[] 6 River, irrigation ditch, spring or similar
[] 7 Neighbor
[] 8 Other

If you circled any number between 4 and 8, go to question 6.

5. Does the dwelling have water service seven days a week?

[] 1 Yes

5A. How many hours per day? _ _

[] 2 No

5B. How many days a week? _
5C. How many hours per day? _ _

6. What are the bathrooms or toilets in the dwelling connected to? (Read each option and circle only one number)

[] 1 Public sewer system within the dwelling
[] 2 Public sewer system outside of the dwelling but within the building complex
[] 3 Septic tank
[] 4 Cesspit, latrine
[] 5 River, drainage ditch or canal
[] 6 Doesn't have

7. Does the dwelling receive electric lighting from the public network?

[] 1 Yes
[] 2 No

8. How many rooms does the dwelling have in total, excluding the bathroom, kitchen, and garage?

Number of rooms _ _

9. Is the dwelling you occupy (Read each option and circle only one number):

[] 1 Rented
[] 2 Owned, taken over [propia por invasión]
[] 3 Owned, paying off in installments
[] 4 Owned, completely paid for
[] 5 Given by job or another household/institution
[] 6 Other

[p. 2]
Third section: Household characteristics
[Questions 1-4]

1. Does the household have (read each option and circle one or more numbers):

1A. Household Electrical Appliances

[] 1 Radio
[] 2 Color television
[] 3 Audio equipment
[] 4 Washing machine
[] 5 Refrigerator or freezer
[] 6 Computer
[] 7 None

1B. Services

[] 1 Landline phone
[] 2 Cell phone
[] 3 Internet connection
[] 4 Cable TV connection
[] 5 None

2. What is the most common energy or fuel used in the household for cooking? (Read each option and circle only one number)

[] 1 Electricity
[] 2 Gas
[] 3 Kerosene (go to 2A)
[] 4 Coal (go to 2A)
[] 5 Wood (go to 2A)
[] 6 Manure (go to 2A)
[] 7 Other
[] 8 Do not cook

2A. Does the kitchen have a chimney?

[] 1 Yes
[] 2 No

3. How many of the people who used to be part of this household are living permanently in another country?

Number of persons _

If the answer is none, write 0.
If the answer is 10 or more, write 9.

4. Is there anyone with a disability, that is, a person with a permanent physical or mental impairment which limits one or more of his/her activities of daily living? Does anyone in this household have a permanent impairment or restriction? (Read each option and circle one or more numbers)

[] 1 Vision, even when using glasses
[] 2 Hearing, even when using hearing aids
[] 3 Speaking (voicing/vocalizing [entonar/vocalizar])
[] 4 Using arms and hands/legs and feet
[] 5 Other impairment or restriction
[] 6 No one with a disability

Fourth section: Household make-up (only for the head of the household).
[Questions 1-2]

1. How many people slept here the day before Census Day? Don't forget newborns, seniors, and visitors.

Write the answer in the space _ _

2. What is the name and paternal surname of each of the people who slept here the night before the census day? Don't forget to record newborns, seniors, and visitors.

Record people in the following order:

- Head of household
- Spouse or partner
- Single children and/or stepchildren and/or adopted children without children. Record by age, from oldest to youngest.
- Single children and/or stepchildren and/or adopted children with children. Record by age, from oldest to youngest, followed by their children.
- Married or partnered children and/or stepchildren and/or adopted children, and their family.
- Sons-in-law/daughters-in-law
- Grandchildren
- Parents and parents-in-law
- Other relatives (aunts and uncles, siblings, etc.)
- Household workers
- Boarders
- Other persons not related to the head of household (friends, co-godparents, etc.)

"Household make-up" [table]:

[Column headings:]
(A) Order number (01 through 10)
(B) Name and Paternal Surname of the Person

If there are more than 10 people in the household, use one or more additional forms, as necessary.

Enumeration Summary

For Individual Dwellings: When you have finished enumerating the household, review the census form you used and verify that the number of people enumerated in the fifth section is equal to the number of people recorded in the fourth section. Then add up the total number of people in the fifth section by sex and write them in the respective grid spaces.

For Collective or Other Dwellings: When you have finished the enumeration, review the fifth section of the census forms you used, add up the total number of people by sex and write them in the respective grid spaces.

_ _ _ _ _ Total
_ _ _ _ _ Men
_ _ _ _ _ Women

Fifth section: Population characteristics
[Questions 1-26]

____ Person number
____ Name:

For all persons
[Applies to questions 1-8]

1. What is your relation to the head of household? (circle only one number)

[] 1 Head of household
[] 2 Spouse or partner
[] 3 Child/step-child
[] 4 Son-in-law/daughter-in-law
[] 5 Grandchild
[] 6 Parents/parents-in-law
[] 7 Other relative
[] 8 Household worker
[] 9 Boarder
[] 0 Other unrelated person

2. Sex

[] 1 Male
[] 2 Female

3. How old are you in completed years?

If one or more completed years, write only years: _ _
(If more than 98, write 98)

If less than one year, write only months: _ _
(If less than one month, write 0)

4. Do you have birth certificate on file with the civil registry office?

[] 1 Yes
[] 2 No

5. Do you live permanently in this district?

[] 1 Yes (go to question 6)
[] 2 No (go to question 5A)

5A. In which district or department do you live permanently?

________ District
________ Department/Country
(If the person lives abroad, only write the name of the country)

6. Were you living in this district five years ago?

[] 1 Not yet born (go to question 7)
[] 2 Yes (go to question 7)
[] 3 No (go to question 6A)

6A. In which district or department were you living five years ago?

District ____
Department/Country ____
(If living abroad, only write the name of the country)

7. When you were born, did your mother live in this district?

[] 1 Yes (go to question 8)
[] 2 No (go to question 7A)

7A. What district and department was your mother living in?

District ____
Department/Country ____
(If living abroad, only write the name of the country)

8. What kind of insurance do you have? (Read each option and circle one or more numbers)

[] 1 Comprehensive health insurance [Sis] sponsored by the Government and targeted to poor and low income people
[] 2 Government health plan for all employed workers and people receiving retirement income [Essalud]
[] 3 Other health insurance
[] 4 None

For persons aged three or older
[Applies to questions 9-12]

9. What was the first language you learned to speak? (Read each option and circle only one number)

[] 1 Quechua
[] 2 Aymara
[] 3 Asháninka
[] 4 Other indigenous language

Specify ________

[] 5 Spanish
[] 6 Foreign language
[] 7 Is deaf-mute

10. Do you know how to read and write?

[] 1 Yes
[] 2 No

11. What was the last level and grade or year you successfully completed in school? (Circle only one number. For primary write the grade or year and for secondary [high school] write only the year)

[] 1 No level
[] 2 Initial Education
[] 3 Primary

Grade _
Year _

[] 4 Secondary [High school]

Year _

[] 5 Non-university higher education -- incomplete
[] 6 Non-university higher education -- complete
[] 7 University higher education -- incomplete
[] 8 University higher education -- complete

12. Do you currently attend a high school, school, college or university?

[] 1 Yes
[] 2 No

For persons aged six or older
[Applies to questions 13-19]

13. Did you work at least one hour last week for payment in cash or kind?

[] 1 Yes (go to question 16)
[] 2 No

14. Last week did you (Read each option and circle only one number):

[] 1 Not work, though you had a job?
[] 2 Have your own business, though you did not work?
[] 3 Do some odd job for payment in cash or kind?
[] 4 Help out on the farm or in the store or business of a family member without receiving pay?
[] 5 Not work?

If you circled any number between 1 and 4, go to question 16.

15. Last week were you (Read each option and circle only one number):

[] 1 Looking for work and have worked before?
[] 2 Looking for work for the first time?
[] 3 Studying and did not work?
[] 4 Living off a pension or retirement income and did not work?
[] 5 Living off investment income and did not work?
[] 6 Taking care of the house and did not work?
[] 7 Other?

Specify ________

Go to question 20.

16. What was your main employment last week?

(Examples are: Secondary education teacher, lawyer, agricultural laborer, food sales in the street, etc.)

Specify ________

17. What type of activity did the business, organization or company in which you work engaged last week?

(Examples are: manufacture clothing, rice growing, raising cattle, wholesale grocery sales, restaurant, etc.)

Specify ________

18. What type of employment did you have at your job last week? (Read each option and circle only one number)

[] 1 White-collar or professional employee
[] 2 Laborer
[] 3 Self-employed worker
[] 4 Employer
[] 5 Unpaid family worker
[] 6 Domestic employee

19. How many people worked at your place of employment last week? (Read each option and circle only one number)

[] 1-5 people
[] 6-10 people
[] 11-50 people
[] 51 people or more

For people aged twelve or older
[Applies to questions 20-21]

20. What religion are you? (Circle only one number)

[] 1 Catholic
[] 2 Christian/Evangelical
[] 3 Other
[] 4 None

21. What is your current civil or marital status? (Circle only one number)

[] 1 Cohabiting
[] 2 Separated
[] 3 Married
[] 4 Widowed
[] 5 Divorced
[] 6 Single

For women aged twelve or older
[Applies to questions 22-25]

22. How many live-born children have you had in total?

Total _ _
(If she has not had any children, write 0 and go to question 26)

23. How many of your children are still living?

Total _ _
(If she has not living children, write 0)

24. In what month and year was your last live-born child born?

Month _ _
Year _ _ _ _

25. How old were you when your last live-born child was born?

Age in years _ _

For persons aged eighteen or older
[Applies to question 26]

26. Do you have a national ID card?

[] 1 Yes
[] 2 No

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