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List of questions to the sample survey

Dwelling Module

1. Is the dwelling in which you reside situated in a block of flats?

[] 1) Yes
[] 2) No

2. This dwelling is your:

[] 1) Permanent (usual) residence
[] 2) Temporary residence (i.e. it is a secondary dwelling intended for temporary or seasonal stay)

3. Dwelling in which you reside is owned by:

[] 1) A private person
[] 2) A co-operative member
[] 3) A co-operative condominium
[] 4) A municipality (gmina)
[] 5) State Treasury
[] 6) A company
[] 7) A building society
[] 8) Other entity

4. Usable floor space of dwelling in which you reside -- total ____ (Please specify in round m2 [square meter])

5. Usable floor space of this dwelling used solely for the purpose of conducting economic activity ____ (Please specify in round m2 [square meter])

6. Number of rooms in this dwelling

____ 1) Total
____ 2) Of which rooms used solely for the purpose of conducting economic activity

7. Is there a kitchen in dwelling in which you reside?

[] 1) There is a kitchen space -- with a window and the area of 4 m2 [square meter]) or more ____ (Please specify the number of kitchens)
[] 2) There is a kitchen space without any window (the so-called dark kitchen) or with the area of less than 4 m2 [square meter]
[] 3) There is a room with a kitchenette
[] 4) There is neither a kitchen space with or without window, nor a room with a kitchenette

Fitting of dwelling with installations

Please indicate active and temporarily inactive installations (except for those installations which have been inactive for over one year, due to serious breakdowns). Please indicate also those appliances which have already been installed, but which not been connected to the network yet (e.g. in a newly-constructed building).

8. Is there a tap with running water in dwelling in which you reside?

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

9. Is there a bathroom with a bath tub or a shower in this dwelling?

[] 1) Yes
[] 2) No

10. Is there a flushable toilet in this dwelling?

[] 1) Yes
[] 2) No

11. Is there a gas supply in this dwelling?

[] 1) Yes, from a gas-line system
[] 2) Yes, from a gas cylinder
[] 3) No

12. Heating of this dwelling

[] 1) Central heating from a collective system
[] 2) Central heating from a collective source of heat supply to one block of flats
[] 3) Individual central heating system
[] 4) Boilers
[] 5) Other

13. Type of fuel used

[] 1) Solid fuel
[] 2) Gaseous fuel
[] 3) Liquid fuel
[] 4) Electricity
[] 5) Dual fuel system
[] 6) Other

Building module

1. Type of building in which dwelling in which you reside is situated:

[] 1) Residential
[] 2) Institutional (e.g., a hotel, a sanatorium, a student dormitory, a boarding school, a monastery, etc.)
[] 3) Non-residential (i.e., a building meant for non-residential purposes, e.g. an out-patient clinic, a school, etc.)

2. Number of dwellings in the building ____ (Please specify the number)

3. Form of building ownership:

[] 1) Natural person
[] 2) Housing cooperative
[] 3) Gmina
[] 4) State treasury
[] 5) Company
[] 6) Public building society
[] 7) Other entity
[] 8) Joint ownership with separate ownership to residential dwellings
[] 9) Joint ownership without separate ownership to residential dwellings

4. Building completion year:

[] 1) Year _ _ _ _
[] 2) Under construction

5. Is there a water system in the building?

[] 1) Yes -- from a water-line system
[] 2) Yes -- local
[] 3) No

6. Is there a sewerage system in the building?

[] 1) Yes -- with discharge to a sewerage network
[] 2) Yes -- local
[] 3) No

1. Residence address
(voivodship, powiat, gmina, locality, street, property number, flat number)

Table 1. Compilation of persons in a dwelling (sample survey)

This table indicates all persons who are registered in this dwelling.
Please provide also the names of any persons who are not registered in this dwelling, but who are staying in it (as of 31 March).

Information should be given by one adult who can most accurately describe the situation of all persons residing at this address, as well as provide the dwelling and building description.

1. Number of the person in dwelling _ _

2. Surname -- 1st part ____

3. Surname -- 2nd part ____

4. First name ____

5. Middle name ____

6. PESEL identification

[] 1) The person is a child to whom no PESEL has been given
[] 2) The person is a foreigner to whom no PESEL has been given
[] PESEL number: ____

7. Sex

[] 1) Male
[] 2) Female

8. Date of birth _ _-_ _-_ _ _ _

Day-Month-Year

9. Residence status

[] 1) Registered for permanent residence
[] 2) Registered for temporary stay
[] 3) Resides permanently
[] 4) Stays temporarily
[] 5) Does not reside at this address (Note: person answering question No 5 should move to questions No 6,7, and 8 in the personal form and complete only them.)

Table 2. Number of households in a dwelling and relationships between household members

Having accepted the composition of persons in a dwelling, please indicate the person considered representative of each household by highlighting the line with his/her surname and name.

1. No. of the person in dwelling _ _

2. Surname -- 1st part ____

3. Surname -- 2nd part ____

4. First name ____

5. Middle name ____

6. Please indicate the relevant household number for each household member ____

7. What is the relationship between you and the person considered representative

[] 1) Representative of household No. 1
[] 2) Husband/wife /partner
[] 3) Son - daughter
[] 4) Father - mother
[] 5) Father-in-law - mother-in-law
[] 6) Son-in-law - daughter-in-law
[] 7) Brother - sister
[] 8) Grandfather - grandmother, great-grandfather - great-grandmother
[] 9) Grandson - granddaughter
[] 10) Other relative (e.g., sister-in-law, brother-in-law, nephew, uncle)
[] 11) Unrelated person

[] 1) Representative of household No. 2
[] 2) Husband/wife /partner
[] 3) Son - daughter
[] 4) Father - mother
[] 5) Father-in-law - mother-in-law
[] 6) Son-in-law - daughter-in-law
[] 7) Brother - sister
[] 8) Grandfather - grandmother, great-grandfather - great-grandmother
[] 9) Grandson - granddaughter
[] 10) Other relative (e.g., sister-in-law, brother-in-law, nephew, uncle)
[] 11) Unrelated person

8. Please insert the number of the person being the husband/wife/partner from column 1 _ _

Please insert the number of the person being the parent and remaining in the common household
[Questions 9-10]

9. Father's No. _ _

10. Mother's No. _ _

Additional information about households

(Please give information for each household in your dwelling)

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

Please mark the source of income which for the last 12 months has been the principal source of maintenance of the household established in your dwelling
[] 1. Income from hired work in the public sector
[] 2. Income from hired work in the private sector
[] 3. Income from self-employment outside agriculture
[] 4. Income from self-employment in agriculture
[] 5. Income from renting
[] 6. Income from property
[] 7. Retirement pay (for employees, combatants, farmers)
[] 8. Structural pension
[] 9. Pension resulting from an inability to work, pension for invalids
[] 10. Family pension
[] 11. Social pension
[] 12. Unemployment benefit
[] 13. Pre-retirement benefit or allowance
[] 14. Social assistance benefits
[] 15. Other sources of income not elsewhere specified

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

In case the household has an additional source of income, please indicate the relevant symbol using the response to question 1.

Any such additional source may not be identical as the main source.
[] 1. Income from hired work in the public sector
[] 2. Income from hired work in the private sector
[] 3. Income from self-employment outside agriculture
[] 4. Income from self-employment in agriculture
[] 5. Income from renting
[] 6. Income from property
[] 7. Retirement pay (for employees, combatants, farmers)
[] 8. Structural pension
[] 9. Pension resulting from an inability to work, pension for invalids
[] 10. Family pension
[] 11. Social pension
[] 12. Unemployment benefit
[] 13. Pre-retirement benefit or allowance
[] 14. Social assistance benefits
[] 15. Other sources of income not elsewhere specified
[] 16. No additional source

2. On what basis is the dwelling occupied?

(Concerns households residing in dwellings)
[] 1. Ownership right to the dwelling or house (does not concern housing cooperatives)
[] 2. Cooperative ownership right to the dwelling (member-owned dwelling or condominium)
[] 3. Rental (dwelling occupied under a tenancy agreement or function dwelling allocation)
[] 4. Sub-rental (as sub-tenant)
[] 5. Kinship (with owner or main tenant) or perpetual usufruct right
[] 6. Other

Did the household in 2002 comprise persons who went abroad after 2002 for permanent residence and who are not included in the composition of persons (i.e. who have deregistered from permanent residence)?

[] 1. Yes (please indicate the number and complete the table)
[] 2. No
(2) No. _ _
(3) Name and surname ____
(4) Sex
[] 1. Female
[] 2. Male
(5) Date of birth ____
(6) Year of departure from Poland _ _ _ _
(7) Country of residence (index of countries) ____

A. Personal form to the sample census

1. Module -- Socio-demographic characteristics

1. Person No. _ _

2. Surname -- 1st part ____

3. Surname -- 2nd part ____

4. First name ____

5. Middle name ____

6. PESEL ____

If a person does not have a PESEL, please specify whether:

[] 1) He/she is a child to whom no PESEL has been given
[] 2) He/she is a foreigner to whom no PESEL has been given

7. Sex

[] 1. Male
[] 2. Female

8. Date of birth _ _-_ _-_ _ _ _

Day-Month-Year

9. Do you reside in this dwelling permanently, and were you present in or absent from this dwelling on 31 March, or do you stay here temporarily?

[] 1. Residing permanently -- present
[] 2. Residing permanently -- absent, temporarily staying in the country ____
Please specify the locality, gmina, powiat and voivodship of temporary stay
[] 3. Residing permanently -- absent, temporarily staying abroad ____
Please specify the country
[] 4. Staying temporarily -- arrived from another locality in the country ____
Please specify the locality, gmina, powiat and voivodship of permanent residence
[] 5. Staying temporarily -- arrived from abroad ____
Please specify the country

10. How long have described person not been living in this dwelling?

[] 1. Less than one year
[] 2. One year or longer

11. Is described person place of residence known?

[] 1. Yes
[] 2. No

12. Please specify described person place of residence.

[] 1. Other in the country ____
Please specify the locality, gmina, powiat and voivodship
[] 2. Abroad ____
Please specify the country

13. What is the actual period of your temporary stay (from arrival to 31 March 2011)?

[] 1. Up to 3 months (inclusive)
[] 2. More than 3 months but less than 12 months
[] 3. 12 months or longer
13. b Please specify the year of your arrival to Poland: _ _ _ _ (concerns persons arriving from abroad)

14. What is the actual period of your temporary absence (from departure to 31 March 2011)?

[] 1. Up to 3 months (inclusive)
[] 2. More than 3 months but less than 12 months
[] 3. 12 months or longer
14. b Please specify the year of your departure from Poland: _ _ _ _ (concerns persons staying abroad)

15. What is your intended period of temporary stay (from arrival to planned departure)?

[] 1. Up to 3 months (inclusive)
[] 2. More than 3 months but less than 12 months
[] 3. 12 months or longer

16. What is your intended period of temporary absence (from departure to planned return)?

[] 1. Up to 3 months (inclusive)
[] 2. More than 3 months but less than 12 months
[] 3. 12 months or longer

17. Please specify the main reason of your temporary stay

(Question asked to persons arriving from another locality within the country)
[] 1. Work
[] 2. Education
[] 3. Family formation
[] 4. Joining my family
[] 5. Accompanying my family
[] 6. Medical treatment, rehabilitation
[] 7. Housing conditions
[] 8. Necessity to receive care from my family or institution
[] 9. Other

18. Please specify the main cause of your temporary absence

(Question asked to persons temporarily staying in another locality within the country)

[] 1. Work
[] 2. Education
[] 3. Family formation
[] 4. Joining my family
[] 5. Accompanying my family
[] 6. Medical treatment, rehabilitation
[] 7. Housing conditions
[] 8. Necessity to receive care from my family or institution
[] 9. Other

19. Please specify the main cause of your temporary stay

(Question asked to persons arriving from abroad)

[] 1. Work
[] 2. Education
[] 3. Family matters
[] 4. Medical treatment, rehabilitation
[] 5. Seeking international or national protection
[] 6. Other

20. Please specify the main cause of your temporary absence

(Question asked to persons temporarily staying abroad)
[] 1. Work
[] 1.1 Difficulties with finding a job in the country
[] 1.2 Jobs inconsistent with my qualifications
[] 1.3 Higher salaries abroad
[] 1.4 Wider opportunities to develop professional career abroad
[] 1.5 Interesting job offers abroad
[] 1.6 Delegation by my employer
[] 1.7 Economic activities conducted abroad
[] 1.8 Other
[] 2. Education
[] 2.1 Studies/learning
[] 2.2 Stay connected with scientific scholarship
[] 2.3 Improving professional qualifications (courses, internships)
[] 2.4 Learning (improving the command) of a foreign language
[] 2.5 Other
[] 3. Family matters
[] 3.1 Family formation
[] 3.2 Joining my family
[] 3.3 Dissolution of my marriage/cohabitation
[] 3.4 Accompanying my family
[] 3.5 Other
[] 4. Medical treatment, rehabilitation
[] 5. Other

21. What is your marital status?

(Concerns people aged 15 years or more)

[] 1. Single
[] 2. Married (in actual status of marriage)
[] 3. Married (in separation adjudicated by court)
[] 4. Married (not in the actual status of marriage but without separation adjudicated by court)
[] 5. Widower/widow
[] 6. Divorced

22. Please specify the date of contracting marriage or establishing cohabitation, in which you are currently staying. _ _-_ _-_ _ _ _

(Please indicate a full date: day-month-year)

23. Non-obligatory question. Was your current relationship formally established in a registry office or in a church (religious association)?

[] 1. Yes
[] 2. No
[] 3. I don't want to answer this question

2. Module -- Education

(Questions concern persons aged 13 years or more i.e. born on 31.03.1998 or earlier)
[Questions 1-6 were asked of persons aged 13 years or more i.e. born on 31.03.1998 or earlier.]

1. What is your highest educational level achieved in the education system?

[] 1. Tertiary, at least with a degree of Doctor's (Ph.D.)
[] 2. Tertiary, with a degree of Master (MA, MSc), Medical Doctor or equivalent
[] 3. Tertiary with a degree of Engineer, Bachelor, or certified economist
[] 4. College diploma
[] 5. Post-secondary with secondary education completion certificate ("Matura" - Baccalaureate)
[] 6. Post-secondary without secondary education completion certificate ("Matura" - Baccalaureate)
[] 7. Secondary vocational with secondary education completion certificate ("Matura" - Baccalaureate)
[] 8. Secondary vocational without secondary education completion certificate ("Matura" - Baccalaureate)
[] 9. General secondary with secondary education completion certificate ("Matura" - Baccalaureate)
[] 10. General secondary without secondary education completion certificate ("Matura" - Baccalaureate)
[] 11. Basic vocational
[] 12. Lower-secondary
[] 13. Primary
[] 14. Incomplete primary or no education

2. What is your field of education? ____

3. What is your specialty education? ____

4. What is your trained occupation? ____

5. Are you continuing your education?

[] 1. Yes, on a daily/full-time basis
[] 2. Yes, on an evening/weekend (part-time) basis, distance learning
[] 3. No

6. What type of school/studies are you attending?

[] 1. Doctor (Ph.D.) studies
[] 2. Post-graduate studies
[] 3. Higher education institution -- Master studies
[] 4. Higher education institution -- Bachelor or engineering studies
[] 5. College
[] 6. Post-secondary school
[] 7. Technical secondary school
[] 8. Specialized secondary school
[] 9. General secondary school
[] 10. Basic vocational school
[] 11. Lower secondary school
[] 12. Primary school

3. Module -- Economic activity

To be completed for each person aged 15 years or more (i.e. born on 31.03.1996 or earlier).
[Questions 1-25 were asked of persons aged 15 years or more i.e. born on 31.03.1996 or earlier.]

1. Did you perform for at least 1 hour any work providing earnings or income, or help without any contractual remuneration in the family-owned economic activity during the week lasting from 25 to 31 March 2011?

[] 1. Yes
[] 2. No

2. Did you have a job during the week lasting from 25 to 31 March 2011, but you did not temporarily perform it?

[] 1. Yes
[] 2. No

3. a) Did you perform work in your principal workplace during the week lasting from 25 to 31 March 2011 as:

[] 1. Full-time hired employee
[] 2. Part-time hired employee
[] 3. Employer
[] 4. Own-account worker (not hiring any employees)
[] 5. Contributing family worker

b) How would you define your main job?

[] 1. As permanent job
[] 2. As temporary job

4. What job do you perform in your principal workplace? ____

5. a) Is your principal workplace located within the territory of Poland?

[] 1. Yes
[] 2. No

b) Please specify the voivodeship of your principal workplace. ____

c) Please specify the powiat of your principal workplace. ____

d) Please specify the gmina of your principal workplace. ____

e) Please specify the locality of your principal workplace. ____

f) Please specify the street of your principal workplace. ____

g) Do you work in a border area and everyday/regularly commute to work?

[] 1. Yes
[] 2. No

h) Please specify the country of your principal workplace. ____

(According to index of countries)

6. What is the main or dominating type of activity of your principal employer? ____

7. How many hours per week do you usually work in your principal workplace? ____

8. Did you have any additional job during the week lasting from 25 to 31 March 2011?

[] 1. Yes
[] 2. No

9. Did you perform work in your additional workplace during the week lasting from 25 to 31 March 2011 as:

[] 1. Full-time hired employee
[] 2. Part-time hired employee
[] 3. Employer
[] 4. Own-account worker (not hiring any employees)
[] 5. Contributing family worker

10. What job do you perform in your principal workplace? ____

11. What is the main or dominating type of activity of your additional employer? ____

12. Have you ever performed any work providing earnings or income, or help without any contractual remuneration in the family-owned economic activity?

[] 1. Yes
[] 2. No

13. In which year did you stop working?

[] 1. -- 2011
[] 2. -- 2010
[] 3. -- 2009
[] 4. -- 2008
[] 5. -- 2007
[] 6. -- 2006
[] 7. -- 2005
[] 8. -- 2004
[] 9. -- 2003
[] 10. -- 2002
[] 11. -- 2001 or earlier

14. What job did you perform in your last workplace? ____

15. What was the main or dominating type of activity of your last employer? ____

16. Did you perform work in your last workplace as:

[] 1. Hired employee
[] 2. Employer
[] 3. Own-account worker (not hiring any employees)
[] 4. Contributing family worker

17. Why did you stop working?

[] 1. I went on retirement (early retirement)
[] 2. I was granted a pension
[] 3. I lost my job due to liquidation (bankruptcy, restructuring) of my workplace, or due to liquidation of my position
[] 4. I was discharged for other reasons
[] 5. Due to unsatisfactory financial conditions
[] 6. Due to unsatisfactory working conditions, other than financial
[] 7. I completed my temporary or seasonal job
[] 8. To take care of a child or other person who needs to receive care
[] 9. For other family or personal reasons
[] 10. Due to my illness or disability
[] 11. I took up studies or further education
[] 12. I started basic military service
[] 13. For other reasons

18. Were you actively looking for a job in the period from 1 to 31 March 2011?

[] 1. Yes
[] 2. No, I had already arranged for a job and I was waiting for it to start within 3 months
[] 3. No, I had already arranged for a job and I was waiting for it to start after 3 months
[] 4. No

19. How many months were you actively looking for a job? ____

20. Would you be willing to take up a job in the period from 1 to 14 April 2011?

[] 1. Yes
[] 2. No

21. Why are you not looking for a job?

(Please specify one major reason)

[] 1. I am convinced that I will not find any suitable job
[] 2. I have exhausted all means to find a job, which are known to me
[] 3. I am studying or improving my qualifications
[] 4. I take care of children or other people who need to receive care
[] 5. Due to my illness or disability
[] 6. For other family or personal reasons
[] 7. I am on retirement
[] 8. I am expecting to return to work after a break
[] 9. For other reasons

22. Are you a farm user or a member of a household with a farm user?

[] 1. Yes, a farm user
[] 2. Yes, a member of the household with a farm user
[] 3. No

23. Please specify the area of agricultural land of your household (in ha). ____

24. Please specify the number of working months on your farm for the last 12 months. ____

25. How would you describe your situation on the labour market in the week lasting from 25 to 31 March 2011?

(Please select only one answer)

[] 1. I worked only outside agriculture
[] 2. I worked mainly outside agriculture and additionally in agriculture
[] 3. I worked mainly in agriculture and additionally outside agriculture
[] 4. I worked only in agriculture
[] 5. I was unemployed
[] 6. I learnt or studied
[] 7. I was on retirement (early retirement)
[] 8. I didn't work due to bad health (disability)
[] 9. I took care of my home and family
[] 10. I was inactive due to other reasons

4. Module -- Commuting to work

To be completed for each person who in module 3 answered yes to question 5a or no to question 5a but yes to question 5g.

[Questions 1-5 were asked of persons whose principal workplace located within the territory of Poland, or persons whose workplace not located within the territory of Poland but work in a border area and everyday/regularly commute to work, per questions 5a and 5g in module 3.]

1. Do you commute to your main workplace?

[] 1. Yes
[] 2. I have no permanent workplace
[] 3. No

2. What means of transport do you usually use to get to work? (Please specify the means of transport in which you cover the longest distance, or which you use the most frequently)

[] 1. Public transport (including urban)
[] 2. Private carrier
[] 3. Passenger car -- as a driver
[] 4. Passenger car -- as a passenger
[] 5. Train
[] 6. Other

3. How much time does it usually take you to get to work?

[] 1. Up to 30 minutes
[] 2. Between 31 minutes and 1 hour
[] 3. Between 1 hour and 2 hours
[] 4. More than 2 hours

4. What is the distance from your place of residence to your workplace (in kilometers)? ____

5. How often do you commute to work (from your place of residence)?

[] 1. Everyday
[] 2. More often than once a week but not everyday
[] 3. Once a week
[] 4. Once every two weeks
[] 5. Once a month
[] 6. Less frequently than once a month

5. Module -- Source of maintenance

(Concerns persons aged 15 years or more)
[Questions 1-2 were asked of persons aged 15 years or more.]

1. What is your main source of maintenance?

[] 1. Income from hired work in the public sector
[] 2. Income from hired work in the private sector
[] 3. Income from self-employment outside agriculture
[] 4. Income from self-employment in agriculture
[] 5. Income from renting
[] 6. Income from property
[] 7. Retirement pay (for employees, combatants, farmers)
[] 8. Structural pension
[] 9. Pension resulting from an inability to work, pension for invalids
[] 10. Family pension
[] 11. Social pension
[] 12. Unemployment benefit
[] 13. Pre-retirement benefit or allowance
[] 14. Social assistance benefits
[] 15. Other sources of income not elsewhere specified
[] 16. Dependent

2. What is your additional source of maintenance?

[] 1. Income from hired work in the public sector
[] 2. Income from hired work in the private sector
[] 3. Income from self-employment outside agriculture
[] 4. Income from self-employment in agriculture
[] 5. Income from renting
[] 6. Income from property
[] 7. Retirement pay (for employees, combatants, farmers)
[] 8. Structural pension
[] 9. Pension resulting from an inability to work, pension for invalids
[] 10. Family pension
[] 11. Social pension
[] 12. Unemployment benefit
[] 13. Pre-retirement benefit or allowance
[] 14. Social assistance benefits
[] 15. Other sources of income not elsewhere specified
[] 16. No additional source

6. Module -- Disability

1. Has your ability to perform usual activities (learning at school, professional activity, running a household, self-service) been limited due to health problems (disability or chronic disease) for 6 months or longer?

[] 1. Yes, entirely limited
[] 2. Yes, considerably limited
[] 3. Yes, moderately limited
[] 4. No, it is not limited
[] 5. I don't want to answer this question

2. How long has your ability to perform usual activities been limited?

[] 1. From 6 months to 1 year
[] 2. From 1 year to 5 years
[] 3. From 5 years to 10 years
[] 4. 10 years or longer
[] 5. I don't want to answer this question

3. Please specify the cause of your limited ability to perform usual activities:

(Up to 3 options can be marked)

[] 1. Motor organ impairments and diseases
[] 2. Sight impairments and related diseases
[] 3. Hearing impairments and related diseases
[] 4. Circulatory system diseases
[] 5. Nervous system diseases
[] 6. Other diseases not elsewhere specified
[] 7. I don't want to answer this question

4. Do you hold a valid legal confirmation of disability, inability to work or impairment?

[] 1. Yes
[] 2. No
[] 3. I don't want to answer this question

5. How was your disability/inability to work/impairment classified?

[] 1. Considerable disability or complete inability to work and to live self-sufficiently, or the 1st group of disability, or long-term inability to work on a farm with entitlements to nursing benefits;
[] 2. Moderate disability or complete inability to work, or the 2nd group of disability;
[] 3. Slight disability or partial inability to work, or advisability to re-qualify professionally, or the 3rd group of disability, or long-term inability to work on a farm without entitlements to nursing benefits;
[] 4. Disability for persons up to 16 years of age
[] 5. I don't want to answer this question

7. Module -- Fertility, procreation plans

(Concerns woman aged 16-49)
[Questions 1-4 were asked of woman aged 16-49.]

1. Have you given birth to a child?

[] 1. Yes
[] 2. No
[] 3. I don't want to answer this question

2. How many live births have you given?

[] 1. Please specify the number of children, including female _ _
[] 2. I don't want to answer this question

3. How many live births has your mother given?

[] 1. Please specify the number of children _ _
[] 2. I don't know
[] 3. I don't want to answer this question

4. Are you planning to have (more) children?

[] 1. Yes
Please specify the number _ _
[] 2. No
[] 3. I don't know
[] 4. I don't want to answer this question

8. Module -- Country of birth and citizenship

1. What is your country of birth (according to current state borders)?

[] 1. Poland
[] 2. Other
Please specify the country ____

2. What is your father's country of birth (according to current state borders)?

[] 1. Poland
[] 2. Other
Please specify the country ____
[] 3. I don't know

3. What is your mother's country of birth (according to current state borders)?

[] 1. Poland
[] 2. Other
Please specify the country ____
[] 3. I don't know

4. What is your citizenship?

[] 1) Polish (only Polish or Polish and other)
[] 2) Only other
Please specify the country of your citizenship ____
[] 3) Stateless person (person with no citizenship)

5. Are you a citizen of any other country apart from the aforementioned?

[] 1. Yes
Please specify the country/countries (2 names of countries of citizenship may be inserted) ____
[] 2. No

6. Have you held the Polish citizenship since your birth?

[] 1. Yes
[] 2. No
Please specify the country of your previous citizenship ____

9. Module -- Internal and international migration

1. Have you lived in the locality of your current address since you were born (i.e. continually or with breaks shorter than one year)?

[] 1. Yes
[] 2. No

2. When did you arrive or return to the locality of your current residence (indicated in your address of residence)?

[] 1. I arrived before 1989
[] 2. I returned before 1989
[] 3. I arrived between 1989-2001
[] 4. I returned between 1989-2001
[] 5. I arrived before 2002-2010
Please specify the year of arrival; for years 2009 -- 2010 please indicate the month and year ____
[] 6. I returned between 2002-2010
Please specify the year of return; for years 2009 -- 2010 please indicate the month and year ____

3. Please specify the place of your previous (last) residence (the place where you stayed for at least one year)

[] 1. Another locality in the same gmina
Please mark the type of locality:
[] 1) Urban
[] 2) Rural
[] 2. Other gmina
Please specify the gmina, powiat and voivodship ____
[] 3. Other country
Please specify the country ____

4. Please specify the main cause of your arrival (return) to your current place of residence

(Question asked to permanent residents arriving from other locality within the country)

[] 1. Work
[] 1.1 Loss of work or difficulties with finding a job in my previous place of residence
[] 1.2 More interesting job offer
[] 1.3 Tiring commuting to work
[] 1.4 Other
[] 2. Education
[] 2.1 Taking up studies/learning
[] 2.2 Improving professional qualifications (extracurricular forms)
[] 2.3 Return to hometown after the completion of studies
[] 2.4 Other
[] 3. Family matters
[] 3.1 Family formation
[] 3.2 Joining my family
[] 3.3 Accompanying my family
[] 3.4 Other
[] 4. Health
[] 4.1 Medical treatment, rehabilitation
[] 4.2 Better access to health care
[] 4.3 Necessity to receive care from my family
[] 4.4 Other
[] 5. Housing conditions
[] 5.1 Lack of independence of living in my previous place of residence
[] 5.2 Poor housing conditions in my previous place of residence (e.g., too small flat, no running water...)
[] 5.3 High housing costs in my previous place of residence
[] 5.4 Attractive surroundings to settle down (to build/purchase a house/flat)
[] 5.5 Other
[] 6. High maintenance costs in my previous place of residence
[] 7. Other

5. Please specify the main cause of your arrival to your current place of residence

(Question asked to permanent residents arriving from abroad)

[] 1. Work
[] 2. Education
[] 3. Family matters
[] 4. Repatriation
[] 5. Other

6. In how many localities within the country (including the current one) have you lived in your entire life for at least one year? ____

7. Have you ever stayed abroad for at least one year?

[] 1. Yes -- I arrived from abroad and I have lived in Poland continually (or with breaks shorter than one year)
Please specify the year of arrival to Poland and the country of your previous residence ____
[] 2. Yes -- I departed abroad and I returned to Poland
Please specify the year of arrival to Poland after your last departure lasting one year or longer, and the country of your previous residence ____
[] 3. I have never stayed abroad for at least one year

8. How long did you stay abroad? ____

Please specify the number of years of your last stay lasting one year or longer.

9. Please specify the main cause of your last departure abroad

(Question asked to persons who departed abroad and returned)
[] 1. Work
[] 1.1 Difficulties with finding a job in the country
[] 1.2 Job inconsistent with my qualifications
[] 1.3 Higher salary abroad
[] 1.4 Wider opportunities to develop professional career abroad
[] 1.5 Interesting job offer abroad
[] 1.6 Delegation by my employer
[] 1.7 Intent to conduct economic activity abroad
[] 1.8 Other
[] 2. Education
[] 2.1 Studies (learning)
[] 2.2 Stay connected with scientific scholarship
[] 2.3 Improving professional qualifications (courses, internships)
[] 2.4 Learning (improving the command) of a foreign language
[] 2.5 Other
[] 3. Family matters
[] 3.1 Family formation
[] 3.2 Joining my family
[] 3.3 Accompanying my family
[] 3.4 Other
[] 4. Medical treatment, rehabilitation
[] 5. Other

10. Please specify the main cause of your return to Poland

(Question asked to persons who departed abroad and returned)

[] 1. Improvement of the situation on the labour market in Poland
[] 2. Intent to set up economic activity in Poland
[] 3. Saving the planned amount of money
[] 4. Loss of work and difficulties with finding a new job abroad
[] 5. Difficulties with finding the first job abroad
[] 6. Contract termination
[] 7. Homesickness
[] 8. Completion of education or studies abroad
[] 9. Going on retirement and planning to spend my retirement in Poland
[] 10. Accompanying my family
[] 11. Other

11. Did you work abroad?

(Question asked to persons who departed abroad and returned)

[] 1. Yes
[] 2. No

12. Was the work performed in line with your qualifications?

(Question asked to persons who departed abroad and returned)

[] 1. Yes
[] 2. No -- below my qualifications
[] 3. No -- above my qualifications
[] 4. I didn't have any qualifications
[] 5. Hard to say

13. What job did you perform before departure abroad?

(Question asked to persons who departed abroad and returned)

[] 1. Before departure I worked as: ____ (Please select from the index of jobs)
[] 2. I didn't work before departure

14. Are you staying in Poland for the first time?

(Question asked to immigrants temporarily staying in Poland)

[] 1. Yes
[] 2. No

15. Is the work performed by you in Poland in line with your qualifications?

(Question asked to immigrants temporarily staying in Poland)

[] 1. Yes
[] 2. No -- below my qualifications
[] 3. No -- above my qualifications
[] 4. I don't have any qualifications
[] 5. Hard to say

16. How would you describe your command of the Polish language?

(Question asked to immigrants temporarily staying in Poland)

[] 1. Very good
[] 2. Good
[] 3. Satisfactory
[] 4. Communication difficulties

17. Are you planning to change your place of residence?

[] 1. Yes -- within the country
[] 2. Yes -- departure abroad
[] 3. No
[] 4. I don't know

18. When are you planning to change your place of residence?

[] 1. Within one year
[] 2. Within a couple of years
[] 3. I don't know

19. For what reason are you planning to change your place of residence?

(Please specify the main reason)

[] 1. Work
[] 2. Education
[] 3. Family matters
[] 4. Necessity to receive care from my family
[] 5. Housing conditions
[] 6. Other

20. Are you planning to return to Poland?

[] 1. Yes
[] 2. No
[] 3. I don't know

21. Are you planning to return to your country of origin/previous residence, or depart to another country?

[] 1. Yes
[] 2. No
[] 3. I don't know

10. Module -- Nationality and language, religious denomination

1a. What is your nationality?

(Understood as the national or ethnical affiliation -- do not confuse with citizenship)

[] 1. Polish
[] 2. Belarusian
[] 3. Czech
[] 4. Karaitic
[] 5. Lithuanian
[] 6. Lemko
[] 7. German
[] 8. Armenian
[] 9. Romany
[] 10. Russian
[] 11. Slovakian
[] 12. Tatar
[] 13. Ukrainian
[] 14. Jewish
[] 15. Other (please specify) ____

1b. Do you feel affiliated also to any other nation or ethnic group?

[] 1. Yes (please specify) ____
[] 2. No

2. What language do you usually speak at home?

(The language you use in everyday contact with your family -- do not confuse with foreign language knowledge)

[] 1. Only Polish
[] 2. Polish and other (please specify) ____
[] 3. Only other (please specify) ____

3. What is your mother tongue?

(The language you learnt as first in your early childhood -- e.g., from your mother)

[] 1. Polish
[] 2. Other (please specify) ____

4. What religious denomination (church or religious association) do you belong to?

[] 1. I belong to:
[] 1) Roman Catholic Church (Catholic Church -- Latin rites)
[] 2) Orthodox Church
[] 3) Jehovah's Witnesses ("The Watchtower" -- the Bible and Tract Society)
[] 4) Evangelical Church of the Augsburg Confession
[] 5) Greek Catholic Church (Catholic Church -- Byzantine-Ukrainian rites)
[] 6) Mariavite Church
[] 7) Pentecostal Church
[] 8) Other (please specify) ____
[] 2. I don't belong to any religious denomination
[] 3. I don't want to answer this question

Other
The above information was provided by:

[] 1. The respondent personally
[] 2. Other household member

Thank you for completing this form