Polish People's Republic
Central Statistical Office
Bureau of Censuses
Poland: form for collecting data on dwelling and its inhabitants
Form A
National Census, 7 December, 1978
For each occupied dwelling, mobile unit or provisional premises a separate form A should be completed.
____ Voidvoship
____ Town
____ Community
____ Locality
____ Type
____ Street (square, circus, etc.)
____ No. of real estate
____ No. of dwelling
____ Number of attached additional forms A
____ No. of census district
____ Successive no. of building in census district
Type of occupied housing unit:
[] 1 Dwelling
[] 2 Mobile unit
Name and first name of lodger (user of dwelling) ____
Useful dwelling space equals the sum of spaces within dwelling, i.e. spaces of rooms, kitchen with window or without it, rooms not occupied or seasonally used, antechamber, bathroom, toilet, pantry chamber, glazed veranda, etc.
(b) Kitchens with window, with floor space of 4 square meters or more ____
(c) Other rooms (e.g. not occupied rooms, seasonally used rooms, rooms for storing household facilities, etc.) Do not include pantry chambers of rural type and dilapidated rooms. ____
3. Space for kitchen not being room
[] 1 There is such a place
[] 0 No such space
[] 1 To the public water supply system
[] 2 To local system
[] 4 As above in point 2
[] 1 To the public water supply system
[] 2 To local system
[] 4 As above in point 2
[] 1 To the public water supply system
[] 2 To local system
[] 4 As above in point 2
[] 2 Without tub or shower
[] 0 There is no bathroom
[] 2 Water heated in dwelling (electric or gas stove), or in central heating boiler for one-family house
[] 0 There are not hot water supplies
[] 2 From bottles
[] 2 Individual, i.e. thermal energy is supplied from boiler in on-family house, or boiler for storey
[] 4 Other types of heating (coal, or gas stoves, etc.)
Census of population (inhabitants) living permanently or temporarily in dwelling
2. First name ____
No. ____
3. Permanently living (whether or not a given person is present in dwelling at the census time), or temporarily staying (please encircle the relevant category)
[] B Permanently living but not present
[] C Temporarily living
4. Please specify for person classified to the category B, or category C, cause of absence or of temporary staying ________
5. For persons listed under category B and C - please specify duration of absence or temporary staying
[] 2 Over 2 months
6. Please write in addresses of permanent living of persons temporarily staying (C) in the enumerated dwelling
____ (b) Street (square, circus, etc.)
____ (c) Gmina (community)
7. Relation to the head of household (please write in respectively: head of household, wife or husband, son, daughter, grandson, father, etc.) ____
8. Sex (please encircle respectively)
[] 2 Female
9. Year of birth (four-digit number) _ _ _ _
10. Marriage status (write in: single, or married, widower, widow, divorced) ____
11. Education attainment (for persons born in 1963 or earlier one of the education categories should be written in) ____
Higher education not completed - after general education
Higher education not completed - after vocational education
Post-secondary completed
Secondary education completed
Secondary education not completed
Basic vocational completed
Primary education completed
Primary education not completed
Self-education
Reading only
Neither writing nor reading
12. Direction in education (please write in: general education, or specialization in mechanics, textile industry, construction, or in agriculture, economics, etc.) ____
13. School attendance (please encircle the relevant)
[] 1 Yes
14. Is he (she), for the reason of his (her) disability or disease, wholly or to a high degree limited in main activities relevant to his (her) age (professional activities, studies, household keeping, etc.; in the case of small children: playing games, etc.)?
[] 1 Yes, wholly
[] 2 Yes, to a high degree
15. Is he (she) recognized by the KIZ (a body consisting of physicians) as disabled person?
[] 1 Yes - I disability group
[] 2 Yes - II disability group
[] 3 Yes - III disability group
16. Main source of maintenance (Encircle the relevant source).
[] A Maintenance from work
[] B Maintenance not from work
[] C Number of breadwinner ____
17 to 20 - Main employment
[Questions 17-20 were asked of the respondent's main employment.]
17. Address of working site (e.g. of building site and not that of headquarter of enterprise)
____ (b) Street (square, circus, etc.)
____ (c) Gmina (community)
18. Name of working establishment ____
If the working establishment is privately owned, beside its name the name and second name of its owner should be written in.
Employee
Commissioner (commission-merchant)
Home-worker
Member of productive cooperative
User of farm
Worker on own account
Aiding in work of ____ (write in the relevant successive number of person enumerated)
Clergyman
20. Write in the name of working post describing precisely type of performed activities or duties ____
21 and 22 - Second employment
[Questions 21 and 22 were asked of the respondent's secondary employment.]
21. Name of work establishment ____
Employee
Commissioner (commission-merchant)
Home-worker
Member of productive cooperative
User of farm
Worker on own account
Aiding in work of ____ (write in the relevant successive number of person enumerated)
Clergyman
23 and 24 - Maintenance not from work
[Questions 23 and 24 were asked of any financial support not from work the respondent has.]
23. Type of such maintenance (e.g. old age or disability pension, scholarship, etc.) ____
25. For professionally not working persons, if he (she) was born in the period 1914-1960, the cause of his (her) inactivity should be specified ____
26. Total area of farm (the item relate to users of farms only) ____
27 and 28 - the items relate to user of farm and all members of his (her) household
[Questions 27 and 28 were asked of respondents who work on farms.]
27. Work contribution to farming (please encircle the relevant contribution)
[] 2 Number of months per year worked on farm
[] 3 Not working on farm
28. For the person concerned write in the year during which he (she) commenced work outside farm, or encircle "nie dotyczy" what means "it does not relate to the person concerned"
[] nie dotzczy: It does not relate to the person concerned.
Information on building where the enumerated dwelling is
As to the topics I, II, IV, and V, relevant symbol number should be encircled; as to the topic III relevant information should be written in.
[] 2 Mixed type: for residential and economic purposes
[] 3 Collective housing unit, i.e. at least a half of it is occupied by boarding school, hotel, hospital, etc.
[] 4 Non-residential
2. Period (year) of construction
[] 9 1918 - 1944
[] 0 1945 - 1970
[] For buildings constructed after 1970 two last digits of construction year should be written in _ _
[] Yes
[] No
4. Height of building (number of floors)
[] 1 One-floor building
[] 2 Two-floor building
[] 3 Three-floor building
[] 4 Four-floor building
[] 5 Five to nine-floor building
[] 6 Ten-floor building
[] 7 Eleven-floor building
[] 8 Twelve and over-floor building
[] 2 Combustible (wood, etc.)
Information on households in dwelling enumerated
1. Right of household to occupying dwelling (or part of dwelling)
Successive number of person being head of household ____
Household occupies dwelling by the right of:
[] 1 Single or shared ownership
[] Membership in housing cooperative
[] 3 Tenant's right
[] 5 Tenure contract (with individual owner, or with member of housing cooperative)
[] 6 Sub-tenure of part or whole of allocated dwelling
[] Relationship with dwelling owner or main tenant
[] 8 Other related person
2. Main source of incomes of households
[] Work outside agriculture:
[] In non-socialized economy:
[] 3 Employment.
[] 5 In State farms, agricultural services, etc.
[] 7 Employment.
[] 9 Others.