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Republic of Poland
Central Statistical Office
May 20th

National Census of Population and Housing 2002

Questionnaire A

____ 1 Voivodship
____ 2 Powiat
____ 3 Community (gmina)
____ 4 Town

5. Precise address of an enumerated dwelling (or other living quarter)

____ Locality
____ Street, number of building, and number of dwelling

____ 6. Serial number of building in enumeration district

____ 7. Number of persons enumerated in the dwelling (or in other living quarters)

8. Type of enumerated housing unit:

[] 1 Dwelling - a portion of space within a building, set of rooms or one room, including auxiliary rooms, regardless if swelling on basis one or more than one legal title

[] 2 Occupied other living quarter (fill in type of quarter or object) ____
It is a quarter not adapted to housing conditions and occupied temporarily (e.g. attic, launderette, drying room), moving object (e.g. barrack, caravan, barge) or other quarter, which during the census is place of residence of an enumerated person
[] 3 Collective living quarter (fill in the full name) ____
It is an object in which stay one more persons, for example: dormitory, hall of residence, workers' hostel, orphanage, borstal, old people's home, humanitarian aid home, convent home, nunnery, hospital, sanatorium, hostel, hotel, motel, guest house or other place
____ Symbol of the type of collective living quarter

Person number (0-15)

____ Family name and given name
____ Year of birth
____ Relationship to the head of the household
____ Number of private household
Number of holders of an agricultural farm (plots of land) in the dwelling ___________

0/IV. Information on private households

1. What is the main and additional source of maintenance of household?

Please fill in only one symbol for each household using explanation:
a) A source of supplying the most incomes for a whole private household,
b) A source of taking the second position in you incomes
a. Main (from 1 to 17 or 19 - notation as in question 30) ____
Fill in the number of household ____
b. Additional (from 1 to 17 or 99 - 'no concern') ____

2. What is the tenure status of household?

[] 1 Ownership of dwelling or building (which does not belong to a housing co-operative)
[] 2 Membership of a housing co-operative (own and rented dwellings)
[] 3 Main tenant
[] 4 Sun-tenant
[] 5 Relationship (with the owner or the main tenant) or for perpetuity
[] 6 Other (i.e. work for the owner of the dwelling, help in the household, live in the building of religious institution etc.) - Specify ____
Fill in the number of household ____

I. Population, private households, families

1 (a) Surname (family name) ____
1 (b) Name (given name) ____

2. Date of birth

_ _ Day
_ _ Month
_ _ _ _ Year

3. Sex

[] 1 Male
[] 2 Female

4. Do you live here permanently and were you present or absent on May 20th at midnight or do you stay here temporarily?

If the answer is: 1 go to question 7; 3 give the name of the country of staying; 5 give the name of the country of origin

[] 1 Live permanently - present - question 7
[] 2 Live permanently - absent
Stay in other place in Poland
[] 3 Live permanently - absent
Stay abroad: Name of the country ____
[] 4 Stay temporarily - arrived from other place in Poland
[] 5 Stay temporarily - arrived from abroad
Name of the country ____

5. What is the real duration of your absence or staying?

If the answer is: 1 in question 5, and 2 or 3 in question 4 go to question 7; 4 in question 5 - if the person stay abroad or arrived from abroad - fill in the year of departure / arriving

[] 1 Up to 2 months
[] 2 Between 2 and 6 months
[] 3 Between 6 and 12 months
[] 4 12 months and more
Year of departure / arriving _ _ _ _

6. What is the reason of your absence or staying?

If the answer is: 1 in the question 5 and 4 or 5 in question 4 - finish enumeration of this person

[] 1 Education
[] 2 Work
[] 3 Family reasons
[] 4 Treatment, convalescence
[] 5 Living conditions
[] 6 Living in health care institution (for child or adult)
[] 7 Other (military)
[] 8 Refugee (for foreigners)
[] 9 Other reasons (specify) ____

7. What is your relationship to the head of private household?

[] 1 Head of household
[] 2 Spouse
[] 3 Cohabitant (common-law partner)
[] 4 Son/ daughter
[] 5 Father/ mother
[] 6 Father-in-law/ mother-in-law
[] 7 Son-in-law/ daughter-in-law
[] 8 Brother/ sister
[] 9 Grandfather / grandmother
[] 10 Grandson/ granddaughter
[] 11 Other relative (specify: e.g. sister-in-law, uncle, niece, etc.) ____
[] 12 Non-relative person (if he/she is a common-law partner of a member of the household please fill in:
Common-law partner of person No ____

In order to separate the families from household fill in the number of parents to all persons, being children of the member of this household - fill in: Child of person No ()
Child of person No ____ and No ____
No of private household ____

8. What is your legal marital status? (Persons age 15 and up)

Concern persons born in 1987 and earlier. If the answer is: 2 or 3 or 6 go to question 9; 1 or 4 or 5 go to question 10

[] 1 Single (never married), go to question 10
[] 2 Legally married (and living together), go to question 9
[] 3 Legally married (living separately), go to question 9
[] 4 Widower - widow, go to question 10
[] 5 Divorced, go to question 10
[] 6 Legally separated (de jure status), go to question 9

9. When a current marriage was contracted? (civil or religious)

_ _ Month
_ _ _ _ Year

Education
(Questions 10 and 11 concern only persons age 13 and up)

10. What is your education level?

(Give the highest level of education completed in the education system)

Higher Education:
[] 1 At least doctorate
[] 2 Master's degree, degree in medicine or equivalent
[] 3 Non-university certificate or diploma (technical institute, licentiate or bachelor or economist)

Post-Secondary:
[] 4 Post-secondary with secondary school certificate
[] 5 Post-secondary without secondary school certificate

Secondary
[] 6 Vocational and technical with certificate
[] 7 Vocational without certificate
[] 8 General with certificate
[] 9 General without certificate
[] 10 Basic vocational

Primary
[] 11 Primary completed

Others
[] 12 Primary not completed and no school education

11. Are you attending school?

[] 1 Yes, at day school
[] 2 Yes, at evening school or weekend school and extramural system
[] 3 No

Disability

12. Are you limited completely or seriously in basic activities of daily life (up to your age), because of disability or chronic disease?

[] 1 Yes, completely
[] 2 Yes, seriously
[] 3 No

13. Do you have a valid certificate of disability?

[] 1 Yes, go to question 14
[] 2 No, go to question 15

14. What is the category of legal confirmation of disability?

[] 1 I highest group (status) of disability
[] 2 II medium group (status) of disability
[] 3 III lowest group (status) of disability

Migration

15. What is the country of your birth?

Please give the name of the country of your birth on the basis of international boundaries existing at the time of the census

[] 1 Poland
[] 2 Other country (specify)
Name of country ____

16. What is your citizenship?

If the answer is 2 or 3 - give the name of the country (ies) of citizenship

[] 1 Polish (only)
[] 2 Both - Polish and other (specify) ________
[] 3 Only others (specify)
________ Name of country
________ Name of country

17. Since when have you lived/stayed in this locality? (urban, rural community - gmina)

If at length of your stay outside a current place of residence in years 1989-2002 was 12 months or more - please fill in answer 3. If the answer is: 1 or 2 - go to question 19; 3 - fill in the year (for years 2001 and 2002 - month and year) and go to question 18

[] 1 Since birth day, go to question 19
[] 2 Since 1988 or longer, go to question 19
[] 3 Since 1989 or shorter, go to question 18
_ _ Month
_ _ _ _ Year

18. Please give the name of the previous place of residence and complete the migration questionnaire M

If the answer is: 1, fill in points a, b, c; 2, give the name of the country of previous residence. For persons absent at least 12 months - do not fill in the migration questionnaire M

[] 1 Other locality in Poland
a) Voivodship ____
b) Community (gmina) ____
c) Type of locality
[] 1 Urban areas
[] 2 Rural areas
[] 2 Abroad
Name of country of previous residence: ____

II. Economic activity of population

(Questions 19 to 29 concern persons age 15 and older)

19. Did you perform any work providing earnings or income or did you help pay in a family business?

If the answer is: 1 or 2 - go to question 20; 3 - go to question 25; 4 - go to question 28

[] 1 Yes, go to question 20
[] 2 You temporarily didn't work due to illness, vacation, lay-off, strike etc., but you did have a job (did not concern contributing family members) in reference week (from May 13th to May 19th), go to question 20
[] 3 No, go to question 25
[] 4 Lack of response (concerns persons staying abroad), go to question 28

Main job

20. Were you employed during the reference week as (concerns the week from May 13th to 19th):

[] 1 Full-time paid-employee
[] 2 Part-time paid-employee
[] 3 Employer
[] 4 Own-account worker (without employees)
[] 5 Agent (in all kind of agencies)
[] 6 Members of agricultural production co-operative
[] 7 Contributing family worker
[] 8 Clergyman/woman

21. What is your occupation?

Please specify name of the performed occupation or position or describe main performed activities: ____

22. What is the main kind of economic activity of the company (institution) in which you have main job?

You may also give the name of a company/institution: ____

Additional job

23. Do you perform any additional job?

If the answer is: 1 - go to question 24; 2 - go to question 28

[] 1 Yes, go to question 24
[] 2 No, go to question 28

24. What is the main kind of economic activity of the company (institution) in which you have additional job?

You may also give the name of the company/institution: ________
Go to question 28.

Seeking employment

(Concerns only persons who did not perform any work providing earnings or income, and did not help pay in a family business.)

25. Are you looking for a job actively?

If the answer is: 1 - go to question 26; 2 - go to question 27; 3 - go to question 28.

[] 1 Yes, go to question 26
[] 2 No, you have found a job and have been waiting to start it, go to question 27
[] 3 No, go to question 28

26. Would you be able to start working in the week from May 13th to May 19th or next providing that found a job?

[] 1 Yes
[] 2 No

27. How long have you been actively looking for a job?

Please, give the number of months: _ _

Holders and members of private households with an agricultural farm (plot) holder

28. Are you a holder of an agricultural farm (plot) or are you a member of a household with an agricultural farm (plot) holder?

If the answer is: 1 - give the size of arable land and go to question 29; 2 - go to question 29; 3 - go to question 30.

[] 1 Yes; you are a holder of the agricultural farm/plot, go to question 29
Size of farm or plot: ____
[] 2 Yes; you are a member of a household with a farm holder, go to question 29
[] 3 No, go to question 30

29. Please give the number of months worked in your agricultural farm (plot) within the last 12 months?

Months _ _

Source of maintenance

30. What is your main source of maintenance?

(It concerns the first position in your incomes)

Incomes from paid-employment
[] 1 In public non-agriculture sector (state and communal establishment)
[] 2 In private non-agriculture sector (including producer's co-operative)
[] 3 In public agriculture sector (state and communal establishment)
[] 4 In private agriculture sector (including producers' co-operative)
Incomes from self-employment (own-account work)
[] 5 Outside agriculture
[] 6 In own private farm (or plot of land)
[] 7 In agriculture outside own private farm (or plot of land)
Non-earned source
[] 8 Retirement pay (employee, derivative and combatant)
[] 9 Retirement pay of farmers
[] 10 Pension resulting from an inability to work
[] 11 Social pension
[] 12 Family pension
[] 13 Unemployment benefit
[] 14 Welfare allowance
[] 15 Others (specify): ____
Other incomes
[] 16 Incomes from owning
[] 17 Incomes from leasing
Maintained by other persons
[] 18 From this household
[] 19 From other household

31. What is your additional (a) source of maintenance (the second position in your incomes)? ____

Put the number from any incomes not maintained by other persons from question 30.
Or, put the number 99 if “no concern”

32. What kind of benefits (b) from non-earned source of income do you receive?

Please use no more than three types of non-earned source of maintenance showed in question 30 (possible answers from “non- earned source” category only)
____
____
____

III. Nationality

33. What is your nationality?

(Don't confuse with citizenship from question 16)

[] 1 Polish
[] 2 Non-Polish (specify):____

34. What is your language most frequently spoken at home?

If the answer is 2 or 3 - fill in the name of one or two languages.

[] 1 Polish only
[] 2 Both Polish and other
Name of non- polish language: ____
[] 3 Only other language (specify)
____ Name of non-polish language
____ Name of non-polish language

V. Characteristics of dwelling

1. Is this dwelling occupied?

[] 1 Yes, and it is only one or main place of residence (at least for enumerated person)
[] 2 Yes, but it is second place occupied temporarily or seasonal
[] 3 Is not occupied/ vacant

Fill in the symbol of non-occupied ____

2. What is the type of ownership of this dwelling?

[] 1 Is owned by a private person
[] 2 Is owed by co-operative dwelling
[] 3 Is tenant by co-operative
[] 4 Is owned by community (gmina)
[] 5 Is owned by state property
[] 6 Is owned by establishment company
[] 7 Is owned by social building company
[] 8 Other type of ownership (specify) ____

3.Is there a kitchen in this dwelling?

[] With a window or floor space less than 4 meters squared
Number of kitchens: __
[] 6 Without a window of floor space less than 4 meters squared
[] 7 Kitchen is a part of the dining or living room
[] 8 No kitchen or a kitchen as a separated part of living room

4. Number of rooms in this dwelling?

a) Total (do not include kitchen, hall, bathroom, toilet, veranda, pantry etc.): ____
b) Of which rooms are used exclusively for conducting economic activity (for example: office, study room, workshop, etc.) ____

5. Useful floor space of this dwelling

(In round meters squared)

a) Total (i.e. total floor space of all lodgings in the dwelling: rooms, kitchens, hall, bathroom, toilet, pantry, veranda, etc.): _____
b) Of which, floor space of dwelling used exclusively for conducting economic activities: ____

6. a) Is there piped water in this dwelling?

[] 1 Yes, both hot and cold water
[] 2 Yes, only cold water
[] 3 No

6. b) Is there piped hot water in this dwelling?

[] 1 Heating outside the dwelling
[] 2 Heating in dwelling or in one family building

7. Is there a bathroom with bathtub and/ or shower?

[] 1 Yes
[] 2 No

8. Is there a flush toilet in this dwelling?

[] 1 Yes
[] 2 No

9. Is there gas in this dwelling?

[] 1 Yes, piped gas
[] 2 Yes, bottle gas
[] 3 No

10. Type of heating of the dwelling

[] 1 Collective central heating: Network
[] 2 Collective central heating: Local source of heating in multi-dwelling building
[] 3 Individual central heating
[] 4 Stores
[] 5 Others (specify): ____

11. The type of fuel or energy used for heating the dwelling

If the answer is 3 or 4 or 5 in question 10 - please give the answer.

[] 1 Constant fuel (coke, coal, patent fuel, wood)
[] 2 Gas (gaseous fuel)
[] 3 Liquid fuel (propulsive fuel, fuel oil)
[] 4 Electricity
[] 5 Two kinds of fuel (i.e. gas-oil, gas-coal, etc.)
[] 6 Others (specify): ____

VI. Characteristics of buildings

1. Type of building

[] 1 Residential
With total number of dwellings: ____
[] 2 Residential- inventoried or residential-farmers
[] 3 Institutional-collective living quarters (more than half of it is occupied for hotel, dormitory, convent, etc.)
[] 4 Non-residential (more than half of it is occupied for offices, dispensary, school etc.)
[] 5 Reserved for seasonal use

2. Who is the owner of this building?

[] 1 Private person
[] 2 Housing co-operative
[] 3 Community (gmina)
[] 4 State property
[] 5 Working establishment company in public sector
[] 6 Working establishment company in private sector
[] 7 Social building company
[] 8 Other (i.e. religious institutions, foundation, association etc.)
Joint ownership (with separate properties of dwellings)
[] 9 Only private persons
[] 10 Private persons and community (gmina)
[] 11 Private persons and working establishments
[] 12 Others
[] 13 Joint-ownership without separate property of dwellings

3. a) Period of the building construction

[] 1 Before 1918
[] 2 1919-1944
[] 3 1945-1970
[] 4 1971-1978
[] 5 1979-1988
[] 6 1989-2002
[] 7 Under construction

3.b) If the answer is 1989 - 2002 - please fill in the year when the building was completed: ____

4. Are there water-pipes in the building?

[] 1 Yes - network
[] 2 Yes - local system
[] 3 No

5. Is there sewage in the building?

[] 1 Yes - connected with sewage system
[] 2 Yes - local system
[] 3 No

Questionnaire D

Female fertility
(Survey concerns women at the age of 16 and over present in the sample dwelling)

(Positions 1-6 are completed by an interviewer on the base of the questionnaire A)
____ 1. Voivodship*
____ 2. Powiat*
____ 3. Community (gmina)*
____ 4. Town*
____ 5. Number of questionnaire A*
____ 6. Number of person on questionnaire A
____ 7. Number of questionnaire D in enumerated dwelling
____ 7a. Number of additional questionnaires D

*Do not fill in marked by the (*) questions (positions)

Answering on questions from 8 to 14 is voluntary. Your participation in this survey is very important, mainly due to small information on determinants of a decline of woman fertility in Poland. Every woman represents ca. 50 women and for this reason a refusal of answer can cause, that survey results could not be representative for all women in Poland.

Only women living in the sample dwelling can give personally answers for questions 8-14. In many cases a sign (X) should be written into boxes besides numbers, other boxes should be filled in Arabic numbers, e.g. November-11. One box should be filled by one number.

8. Date of birth

_ _Day
_ _ Month
_ _ _ _ Year

9. Place of birth

[] 1 Urban area
[] 2 Rural area

10. Are you or have you ever been married or common-law partner?

[] 1 Yes, go to question 11
[] 2 No, go to question 12

11. Please mention in order all legal marriages and common-law partnerships

(Repeat the question for each legal marriage/ common- law partnership)

1. Number of marriage (or common-law relationship)
[] 1
[] 2
[] 3
[] 4
[] 5
2. Has been this marriage contracted? (in civil registration office or religious institution)
[] 1 Yes
[] 2 No
3. Date of marriage contraction (beginning the legal marriage or common-law relationship):
_ _ Month
_ _ _ _ Year
4. Date of marriage dissolution or the end of common-law relationship (if common-low relationship changed into legal marriage with same person, do not fill in the date of the transformation)
_ _ Month
_ _ _ _ Year

12. How many live born children have you born? ____

If the answer is 0, go to question 14

Live born child is an infant, that after separation from its mother breathes or shows and evidence signs of life, e.g. beating of the heart, definite movement of voluntary muscles, crying.

13. Please give the information of all live born children

(Repeat the question for each child)

1. Number of children in order of bearing
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10
2. Given name: ____

3. Sex
[] 1 Male
[] 2 Female
4. Date of birth
_ _ Month
_ _ _ _ Year

14. Are you going to give birth to a child or more children?

For women at age 16-49

[] 1 Yes
Please fill in how many children: ____
[] 2 No
[] 3 I don't know
[] 4 Refused to answer

Thank you very much for your participation in the survey!

Fill in by an interviewer

The reason of non-filling of the questionnaire D (questions 8-14)

[] 1 The sample (enumerated) dwelling without woman
[] 2 Woman is absent during all census period
[] 3 Woman is not interested in participation in this survey

Questionnaire M

Long-term migration

Please complete for person being outside the current place of residence for at least 12 months in 1989-2002

(Positions 1-6 are completed by an interviewer on the base of the questionnaire A)
____ 1. Voivodship*
____ 2. Powiat*
____ 3. Community (gmina)*
____ 4. Town*
____ 5. Number of questionnaire A*
____ 6. Number of person on questionnaire A
____ 7. Number of questionnaire M in enumerated dwelling

*Do not fill in marked (*) questions (positions)

1. Is the current place of stay your permanent residence?

If "yes", please go to question 5; if "no" - go to question 2

[] 1 Yes, go to question 5
[] 2 No, go to question 2

2. Is your permanent residence in Poland or abroad?

If in Poland - go to question 3; if abroad - go to question 4

[] 1 Poland
[] 2 Abroad

3. Please, give the place of your permanent residence in Poland

If it is the same place of permanent residence as has been written in questionnaire A - please, do not fill in this question. Then please go to question 8 on the questionnaire M

a) Voivodship ____
b) Powiat ____
c) Community (gmina) ____
d) Type of locality
[] 1 Urban area
[] 2 Rural area

4. Please, give the name of the country of your permanent residence

If it is the same country of permanent residence as has been written in question 18 in questionnaire A - please, do not fill in this question. Then please go to question 8 on the questionnaire M

Name of country: ____

5. Was the previous (last) place of your residence in Poland or abroad?

If Poland, go to question 6; if abroad, go to question 7

[] 1 Poland, go to question 6
[] 2 Abroad, go to question 7

6. Specify your previous (last) place of residence
(If it is the same place of permanent residence as has been written in question 18 in questionnaire A - please, fill only period of staying (6d). The please go to question 8 on the questionnaire M)

a) Voivodship ____
b) Community (gmina) ____
c) Type of locality
[] 1 Urban areas
[] 2 Rural areas
d) Period of staying
From: Month_ _ Year _ _ _ _
To: Month_ _ Year _ _ _ _

7a) What was the name of the country of your previous residence: ____

(If it is the same country of your permanent residence as has been written in question 18 in questionnaire A - please, fill only period of staying (7b). The please go to question 8 on the questionnaire M)

7b) Period of staying:

From: Month_ _ Year _ _ _ _
To: Month_ _ Year _ _ _ _

8. Has your whole household changed the place of residence?

[] 1 Yes
[] 2 No

9. What was the reason of changing the previous (last) place of residence?

Family reasons:
[] 11 Contraction of marriage
[] 12 Marriage dissolution
[] 13 Family connection
[] 14 Others
Work:
[] 21 More attractive job
[] 22 Job loss
[] 23 A risk of job loss
[] 24 Difficult transport to work
[] 25 Others
Housing conditions:
[] 31 Difficult living conditions
[] 32 Too high cost of living of dwelling
[] 33 Eviction
[] 34 Others
Health:
[] 41 Treatment, convalescence
[] 42 Better access to health care
[] 43 National environment
[] 44 Others
Education:
[] 51 Education in school forms
[] 52 Participation in training occupational programs (in non-school forms)
[] 53 Others
[] 60 Repatriation
[] 70 Refugee (concern foreigners)
[] 80 Others (specify)

10. What was your source of maintenance at the previous place of residence?

(Please, give only one, the main source)

Work in agriculture:
[] 1 In own private farm (plot of land)
[] 2 Paid-employment
Work outside agriculture:
[] 3 Own-account
[] 4 Paid-employment
Non-earned source:
[] 5 Retirement pay
[] 6 Pension (resulting from an inability to work, family pension, etc.)
[] 7 Unemployment benefit
[] 8 Others
[] 9 Other incomes (from owning, leasing)
[] Maintained by other persons (fill in one symbol if 1 to 9) _

11. Is the current place of stay your destination residence?

[] 1 Yes, go to question 12
[] 2 No
If "no" - please fill in no more than three reasons of changing the place of residence (use responses from question 9).
The answers should be filled in order of importance.
Please, stop here the compilation.
____ First reason
____ Second reason
____ Third reason
[] 3 I don’t know, go to question 12

12. Which reasons could cause your decision of changing the place of residence?

Please, fill in no more than three reasons from question 9 in order of their importance.

____ First reason
____ Second reason
____ Third reason