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[Seal of the Republic of Peru]
[Logo: National Institute of Statistics and Informatics (INEI)]


National census 2017: 12th census of population, 7th census of housing and 3rd census of indigenous communities

Census questionnaire

Statistical privacy: confidential information protected by supreme decree no. 043-2001-PCM

____ Housing unit no.

Additional questionnaire
____ Continued from:
____ Main Questionnaire No.

Section I. Location of the housing unit and number of households

A. Geographic location

1. Department

Code _ _
Name ____

2. Province

Code _ _
Name ____

3. District

Code _ _
Name ____

4. Populated area

Code _ _ _ _
Name ________

B. Census location

Urban area
5. Zone No. _ _ _ - _
6. Section No. _ _ _
7. AEU (Urban census area) No. _ _ _
8. Block No. _ _ _ - _
9. Front No. _ _

Rural area

10. Section No. _ _ _
11. AER (Rural census area) No.

_ _ _ Initial
_ _ _ Final

12. Housing unit address (In type of road, fill in only one oval)

Type of road:
[] 1 Avenue
[] 2 Street
[] 3 Jirón [street]
[] 4 Passage
[] 5 Highway
[] 6 Other

Road name ________
Door No. _ _ _ _ - _
Block _ _ _ _ _ _
Interior _ _ _ _ - _
Floor _ _
Block _ _ _ _ _
Lot _ _ _ _
Kilometer _ _ _ _

C. Number of households
(Begin interview with the head of household)

13. Sir/madam, if a household is the person or group of persons who share the same food and other basic needs, how many households occupy this housing unit?

Total households _

14. Household No. _

Section II. Characteristics and services of the housing unit

1. Type of housing unit: by direct observation

(Fill in one oval only)

A. Private housing unit
[] 1 Single family house
[] 2 Apartment in building
[] 3 Housing unit in a house
[] 4 Housing in a tenement house (Alley, lot, backyard)
[] 5 Shack or hut
[] 6 Makeshift dwelling
[] 7 Room not intended for human habitation
[] 8 Other type
B. Collective housing
[If selected, go to section V]

[] 9 Hotel, hostel, lodging, boarding house
[] 10 Health care facility
[] 11 Prison
[] 12 Residential care center for the elderly
[] 13 Residential care center for children and adolescents
[] 14 Convents, monasteries or similar
[] 15 Barracks, camp, base of the Armed Forces or National Police
[] 16 Other type (specify) ____
C. Other type
[If selected, go to section V]

[] 17 On the street (homeless)
[] 18 Gatehouse, port, airport or similar

2. Occupancy status of the housing unit: by direct observation

(Fill in one oval only)

A. Occupied
[] 1 With people present -- Go to question 3
[] 2 With people not present
[] 3 Occasional use
B. Not occupied
[] 4 For rent or for sale
[] 5 Under construction or repair
[] 6 Abandoned or closed
[] 7 Other cause
[If you fill in any number between 2 and 7, go to next housing unit]

Continue interview with the head of the home

3. In the housing unit, is the predominant construction material in the exterior walls:

(Read each alternative and fill in only one oval)

[] 1 Brick or cement block?
[] 2 Stone or masonry block with lime or cement?
[] 3 Adobe brick?
[] 4 Tapia [Rammed earth]?
[] 5 Quincha (cane with mud)?
[] 6 Stone with mud?
[] 7 Wood (pona, tornillo, etc.)?
[] 8 Plywood, zinc, or matting?
[] 9 Other material?

4. In the housing unit, is the predominant construction material of the roof:

(Read each alternative and fill in only one oval)

[] 1 Reinforced concrete?
[] 2 Wood?
[] 3 Shingles?
[] 4 Sheets of zinc, fiber cement or similar?
[] 5 Cane or mat with mud or cement?
[] 6 Plywood / matting / reed?
[] 7 Straw, palm leaves and similar?
[] 8 Other material?

5. In the housing unit, is the predominant construction material in the floors:

(Read each alternative and fill in only one oval)

[] 1 Parquet or polished wood?
[] 2 Vinyl, asphalt sheets or similar?
[] 3 Tiles, terrazzo, ceramic or similar?
[] 4 Wood (pona, tornillo, etc.)?
[] 5 Cement?
[] 6 Dirt?
[] 7 Other material?

Section II. Characteristics and services of the housing unit (continued)

6. Does the water used in the housing unit come mainly from:

(Read each alternative and fill in only one oval)

[] 1 Public network inside the unit?
[] 2 Public network outside the unit, but inside the building?
[] 3 Fountain or basin for public use?
[] 4 Cistern-truck or similar?
[] 5 Well (groundwater)?
[] 6 Spring or pond?
[] 7 River, irrigation canal, lake, lagoon?
[] 8 Other? (specify) ________

[If you fill in any number between 4 and 8, go to question 8]

7. Does the housing unit have water service every day of the week?

(Fill in one oval only)

[] 1 Yes
7A. How many hours a day? _ _
[] 2 No
7B. How many days a week? _
7C. How many hours a day? _ _

8. Do you pay for water service?

[] 1 Yes
[] 2 No -- Go to question 10

9. Which company or entity do you pay for the water service?

(Fill in one oval only)

[] 1 Utility company (EPS - SEDA - EMAPA)
[] 2 Municipality
[] 3 Community organization
[] 4 Cistern-truck (direct payment)
[] 5 Other? (specify) ________

10. Is the bathroom or toilet in the housing unit connected to the:

(Read each alternative and fill in only one oval)

[] 1 Public sewage network inside the unit?
[] 2 Public sewage network outside the unit, but inside the building?
[] 3 Soak pit, septic tank or biodigester?
[] 4 Latrine (treated)?
[] 5 Cesspit?
[] 6 River, irrigation canal, canal or similar?
[] 7 Open field or outdoors?
[] 8 Other?

11. Does the housing unit have electricity lighting from the public grid?

[] 1 Yes
[] 2 No

12. How many rooms in total does the housing unit have excluding the bathroom, kitchen, corridors and garage?

Total rooms _ _

13. Is the housing you occupy:

(Read each alternative and fill in only one oval)

[] 1 Rented?
[] 2 Owned, without property title?
[] 3 Owned, with property title?
[] 4 Leased?
[] 5 Other form? (Specify) ____

Section III. Characteristics of the household

1. In your household, is the energy or fuel you use to cook food:

(Read each alternative and fill in one or more ovals)

[] 1 Electricity?
[] 2 Gas (LPG balloon)?
[] 3 Natural gas (pipeline system)?
[] 4 Coal?
[] 5 Wood?
[] 6 Dung, manure?
[] 7 Other (agricultural waste, etc.)?
[] 8 No cooking

2. Does your home have:
(Read each alternative and fill in only one oval)

1 Sound equipment?
[] Yes
[] No

2 Color TV?
[] Yes
[] No

3 Gas stove?
[] Yes
[] No

4 Refrigerator or freezer?
[] Yes
[] No

5 Washing machine?
[] Yes
[] No

6 Microwave oven?
[] Yes
[] No

7 Blender?
[] Yes
[] No

8 Electric iron?
[] Yes
[] No

9 Computer, laptop, or tablet?
[] Yes
[] No

10 Cell phone?
[] Yes
[] No

11 Landline?
[] Yes
[] No

12 Cable or satellite TV connection?
[] Yes
[] No

13 Internet connection?
[] Yes
[] No

14 Car, truck?
[] Yes
[] No

15 Motorcycle?
[] Yes
[] No

16 Boat, motorboat, canoe?
[] Yes
[] No

3. During the last 5 years, from October 2012 to now, did any person who was a member of this household permanently move to another country?

[] 1 Yes
3A. How many persons? _ _
[] 2 No

Section IV. Persons composing the household (only for the head of the household)

1. How many people slept in this household the night before census day?

Remember to include newborns, older adults, and guests.

Total persons _ _

2. What are the names and surnames of each of the people who slept here the night before census day?

(Remember to record newborns, older adults, and guests)
Write down the persons in the order indicated below:
- Head of household
- Spouse or partner
- Unmarried children, stepchildren and/or adopted children
- Unmarried children, stepchildren and/or adopted children with children
- Married or cohabiting children, stepchildren and/or adopted children and their families
- Son-in-law/daughter-in-law
- Grandchild
- Parents and/or in-laws
- Other relatives (aunts, uncles, siblings, etc.)
- Household worker
- Retired person
- Other people not related to the head of household (friends, close relations, etc.)

No. _ _
Names ____
Paternal surname ____
Maternal surname ____

[This question is to be completed for all persons in the household]

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

Registration summary

In private housing units: At the end of the interview in the household, review the census questionnaire and verify that the number of people counted in Section V. "Characteristics of the Population" is equal to the number of people registered in Section IV. "Persons composing the household." Then add up the total number of people in the fifth section by sex and write it in the respective boxes.

In collective or other type of housing: At the end of the interview, review Section V. "Characteristics of the Population" of the census questionnaires used, add up the total number of persons by sex and write it in the respective boxes.

_ _ _ _ _ Total
_ _ _ _ _ Males
_ _ _ _ _ Females

Section V. Characteristics of the population

Person No. _ _ _ _ _
Name ____

For all persons
[Questions 1-10 were asked of all persons]

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

(Fill in one oval only)

[] 1 Head of household
[] 2 Spouse or partner
[] 3 Child or stepchild
[] 4 Son-in-law or daughter-in-law
[] 5 Grandchild
[] 6 Father- or mother-in-law
[] 7 Sibling
[] 8 Other relative
[] 9 Household worker
[] 10 Boarder or guest
[] 11 Other non-relative

2. Sex

[] 1 Male
[] 2 Female

3. What is the date of birth?

Day _ _
Month _ _
Year _ _ _ _

4. How old is he/she?

Years old: _ _ _

(If younger than 1 year old, write 0)

5. Does he/she live permanently in this district?

[] 1 Yes -- Go to Question 6
[] 2 No
5A. In which district and province?
____ District
____ Province / Country

If living abroad, write the name of the country only.

6. 5 years ago, as of October 2012, was he/she living in that district?

[] 1 Not born yet
[] 2 Yes
[] 3 No
6A. In which district and province did he/she live 5 years ago?
____ District
____ Province / Country

If living abroad, write the name of the country only

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

[] 1 Yes -- Go to question 8
[] 2 No
7A. In which district and province did your mother live?
____ District
____ Province / Country

If living abroad, write the name of the country only

8. Are you insured with:

(Read each alternative and fill in only one oval)

[] 1 Comprehensive Health Insurance (SIS)?
[] 2 ESSALUD?
[] 3 Military or police insurance?
[] 4 Private health insurance?
[] 5 Other insurance?
[] 6 None

9. The following are some questions to find out if you have any permanent difficulty or limitation that prevents you from carrying out your daily activities normally. Do you have any permanent difficulty or limitation for:

(Read each alternative and fill in only one oval)

[] 1 Seeing, even when wearing glasses?
[] 2 Hearing, even with hearing aids?
[] 3 Speaking or communicating, even using sign language or other language?
[] 4 Moving or walking to use arms and/or legs?
[] 5 Understanding or learning (concentrating and remembering)?
[] 6 Relating to others based on thoughts, feelings, emotions, or behaviors?
[] 7 None

10. What is your national identity card number (DNI)?

DNI: _ _ _ _ _ _ _ _

[] 1 Only has birth certificate
[] 2 Only has a Foreigners ID card
[] 3 Does not have any documents
[] 4 Does not remember

For persons of 3 years of age and older
[Questions 11-15 were asked of persons age 3 years or older only]

11. Which language or mother tongue did you first learn to speak when you were a child?

(Read each alternative and fill in only one oval)

[] 1 Quechua
[] 2 Aimara
[] 3 Ashaninka
[] 4 Awajún / Aguaruna
[] 5 Shipibo ? Konibo
[] 6 Shawi / Chayahuita
[] 7 Matsigenka / Machigueng
[] 8 Achuar
[] 9 Other native or indigenous language
[] 10 Spanish
[] 11 Portuguese
[] 12 Other foreign language
[] 13 Peruvian sign language
[] 14 Cannot speak / hear

12. Are you able to read and write?

[] 1 Yes
[] 2 No

13. What is the last level and grade or year of study you passed?

(Fill in one oval only. For elementary school, indicate grade or year)

[] 1 No level
[] 2 Initial
[] 3 Elementary school
Grade or year _
[] 4 High school
Year _
[] 5 Basic special school
Year _
[] 6 Incomplete non-university higher education
[] 7 Complete non-university higher education
[] 8 Incomplete university education
[] 9 Complete university education
[] 10 Master's / doctorate degree

14. Are you currently attending an educational institution, school, high school, or university?

[] 1 Yes
[] 2 No -- Go to question 16

15. Is the educational institution, school, high school, or university you attend located:

(Read each alternative and fill in only one oval)

[] 1 Here, in this district?
[] 2 In another district (Specify)
____ District
____ Province / Country

Section V. Characteristics of the population (continued)

For persons of 5 years of age and older
[Questions 16-23 were asked of persons age 5 years or older only]

16. Last week, did you work to earn an income or to help with production at home?

(Do not consider household chores)

[] 1 Yes -- Go to question 19
[] 2 No

17. Last week:

(Read each alternative and fill in only one oval)

[] 1 You did not work, but had a job (due to vacation, strikes, work stoppage, etc.)?
[] 2 Although you did not work, do you have any business of your own to which you will return?
[] 3 Did you do any occasional work (casual) for payment in cash or in kind?
[] 4 Did you work on a farm or in raising animals?
[] 5 Were you helping in a family member's store or business?
[] 6 Did you do chores at home and did not work?
[] 7 Did not work

[If responded 1-5, go to question 19]

18. Last week, were you actively looking for work?

(Fill in one oval only)

[] 1 Yes
[] 2 No

[If answered, go to question 24]

19. Last week, what was your primary occupation?

(Examples: high school teacher, lawyer, farm hand, farmer, street food vendor, etc.)

(Specify) ____

20. Last week, what activity did you perform in the business, organization, or company in which you work?

(Examples: manufacture of clothing, rice farming, cattle raising, grocery wholesale, restaurant, etc.)

(Specify) ____

21. Last week, at your place of employment did you work as:

[] 1 An employer?
[] 2 An independent or self-employed worker?
[] 3 An employee?
[] 4 A laborer?
[] 5 A worker in a family member's business?
[] 6 As a domestic worker?
[] 7 Other? (specify) ____

22. Last week at your place of employment, including yourself, were there:

(Read each alternative and fill in only one oval)

[] 1 From 1 to 5 people working?
[] 2 From 6 to 10 people working?
[] 3 From 11 to 50 people working
[] 4 From 51 or more people working?

23. Is your workplace located:

(Read each alternative and fill in only one oval)

[] 1 Here, in this district?
[] 2 In another district (Specify)
(If you worked in multiple districts, the last district you worked in)

____ District
____ Province / Country

For persons of 12 years of age and older
[Questions 24-26 were asked of persons age 12 years and older]

24. Currently, what is your marital status?

(Fill in one oval only)

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

25. By your customs and your ancestors, do you feel or consider yourself to be:

(Read each alternative and fill in only one oval)

[] 1 Quechua
[] 2 Aimara
[] 3 Amazonian native or indigenous? (specify) ____
[] 4 Belonging to or part of another indigenous or native people? (specify) ____
[] 5 Black, brown, zambo, mulato, Afro-Peruvian or Afro-descendant?
[] 6 White?
[] 7 Mixed-race (mestizo)?
[] 8 Other? (specify) ____

26. What is your religion?

(Fill one oval only)

[] 1 Catholic
[] 2 Evangelical
[] 3 Other (specify) ____
[] 4 None

For women of 12 years of age and over
[Questions 27-29 were asked of women age 12 years and older]

27. How many total live births have you had?

Total children _ _

[] 1 None -- Conclude the interview

28. How many of your children are currently alive?

Living children _ _

[] 1 None

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

Month _ _
Year _ _ _ _