All-Ukrainian National Census 2001
Number of dwelling within enumeration district ____
List of household members living in this dwelling number ___ and their housing condition ___
Number of census division ____
Number of instructor's point ____
Number of counting point ____
No of dwelling within counting point ____
List of household members living in the dwelling ____
Number of questions in the census portfolio ____
Number of portfolio ____
Republic, Oblast ____
Settlement ____
Prospect, street, square, lane ____
Building number ____
Name of the house owner ____
Apartment number ____
[] Institutional living in quarters (boarding house for old people / invalids, house for orphans, monastery, etc.)
[] Homeless
[] Temporary living
1. List of household members dwelling in this dwelling
For ____ persons
1. No of household member ____
2. Name and surname ____
For residents who are temporarily absent specify
3. Reason of absence ____
4. Duration of absence (number of months or otherwise indicate ?less than a month?) ____
2. Household housing condition
(Temporal residents living in institutional organizations and homeless persons do not reply to the questions 1 - 7)
[] 2 Part of private house
[] 3 Individual apartment
[] 4 Communal apartment
[] 5 Hostel
[] 6 Hotel
[] 7 Other
[] 8 Rented housing
2. Number of occupied living rooms
Part of room ___
3. Space of private house, part of private house, individual or communal apartment (sq. m)
Living ____
4. Do members of your household possess agricultural land plots
[] 2. No
5. If yes, pleased indicate the type of ownership
[] 2. Rented
[] 3. Other
6. What is the total area of your land plots
[] 2. From 0,1 to 0,5 ha
[] 3. From 0,51 to 1 ha
[] 4. From 1.1 to 5 ha
[] 5. From 5.1 to 10 ha
[] 6. Above 10 ha
7. Do you lease your land plots
[] 2. no
Number of census division ____
Number of instructors point ____
Number of counting point ____
Number of dwelling within counting point ____
List of household members living in the dwelling number ____
Number of household member ____
Number of questionnaire within portfolio ____
Number of portfolio ____
1. Relation to the head of the household
[] 2. Wife / Husband
[] 3. Daughter / Son
[] 4. Mother / Father
[] 5. Sister / Brother
[] 6. Daughter / Son in law
[] 7. Mother / Father in law
[] 8. Grandmother / Grandfather
[] 9. Granddaughter/son
[] 10. Other relative relations
[] 11. Do not have relative ties
Number of mother (father) ____
[] 2. Women
[] 2. Residing
Month ____
Year ____
Number of complete years ____
5. Place of birth (indicate: Autonomous Republic of Crimea, Oblast, Kiev, Sevastopol, other country) ____
6. Ethnic Origin (indicate nationality or ethnic group) ____
If Ukrainian is not your mother language, please indicate whether you know Ukrainian fluently
[] 2. No
[] 2 Without
of other country (indicate) ____
9. Family status (for persons aged 15 and above)
[] 2 Married
[] 3 Live with partner
[] 4 Widow / widower
[] 5 Divorced
[] 6 Separated
Number of wife (husband) ____
10 Education (for persons aged 6 and above)
[] 2 Basic high education
[] 3 Primary high education
[] 4 Uncompleted high education (for those who graduated before 1996)
[] 5 Completed secondary education
[] 6 Basic secondary education
[] 7 Primary education
[] 8 Do not have primary education
[] 9 Can't write
Educational institution graduated, number of forms (courses), year of graduation ____
11. Have you graduated vocational school (for persons aged 15 and above)
[] 2 No
12. Type of educational establishment where you enroll (for persons aged 6 and above)
[] 2. Vocational school
[] 3. Secondary school
[] 4. Other
[] 5. Do not study
For persons below age 7 who do not attend school, indicate whether he/she attends preschool establishment
[] 7 No
[] 2 Work for private persons
[] 3 Self-employed (own enterprise)
[] 4 Work performed on the individual basis
[] 5 Work at own agriculture farm
[] 6 Work without payment at family enterprise
[] 7 Work at private subsidiary agriculture
[] 8 Income from property
[] 9 Pension
[] 10 Scholarship
[] 11 Benefits (excluding unemployment allowances)
[] 12 Unemployment allowances
[] 13 Other government social security
[] 14 Dependent
[] 15 Other source
No of the main source of living ____
(Temporary residents do not rely to the questions 14-19)
14. Full name of organization, enterprise, own business, where you performed your main job, type of activity (indicate) ____
15. Your work at the main job ____
(Indicate your occupation, position or work)
16. Whereabouts of your place of work
[] On other territory (specify) ____
(Autonomous Republic of Crimea, Oblast, Kiev, Sevastopol, other country-specify)
[] 2 Member of productive cooperative
[] 3 Employer
[] 4 Self-employed
[] 5 Unpaid family worker
18. Have you lived in this settlement since birth?
[] 2 No
a. If no, indicate the year since which you have been permanently living in this settlement moving to another place falls on period from 5.12.2000 to 5.12.2001 ____
b. Place of your previous residence (specify) ____
(Autonomous Republic of Crimea, Oblast, Kiev, Sevastopol, other country, specify)
c. Type of settlement from which you arrived
[] Rural
d. Are you:
[] Deportee
19. Have you given birth to a child(ren)?
(For females aged 15 and above)
[] 2. No
If yes, specify:
a) Number of children you gave birth to ____
b) Number of living children ____