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Statistics South Africa
Reliable : Relevant : Responsive : Representative
Census 2001
Household questionnaire
For statistical use only

A

Confidentiality
Statistics act no.6, 1999
17(1) Despite any other law, no return or other information collected by Statistics South Africa for the purposes of official or other statistics that relates to an individual or a household may be disclosed to any person.
17(b) Any person who is involved in the collection of, or who may use, that information or data, must first take an oath of confidentiality.
18(e) and 18(g) Any officer of Statistics South Africa who wilfully discloses any data or information obtained in the course of such employment to a person not authorised to receive that information is guilty of an offence and liable on conviction to a fine not exceeding R10 000, or to imprisonment for a period not exceeding six months or to both such fine and such imprisonment.

For office use

_ _ _ _ _ _ _ _ EA number
_ _ _ Record number
_ _ Household number
_ _ Institution number
_ _ Province
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name of local munic.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Main place
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sub-place

____ Physical address
____ Postal code
____ Telephone no
_ How many questionnaires were completed for this household?
_ If more than one questionnaire, what is the number of this questionnaire?
Number of people:
_ _ Total
_ _ Male
_ _ Female

This Questionnaire should be completed for all households living in housing units and collective living quarters including those located in institutions (for example, boarding schools, prisons, hospitals, etc.)

Who completed this questionnaire? Use a dot.
[] An enumerator through an interview
[] A household member through self-completion

Completion of this questionnaire
First fill in the full name of the household head or acting head and the first name of all other persons to be counted. Read every question carefully. Look at the classifications where applicable and find the alternative that best applies to the response. For example, in question P-04 a grandchild belongs to category 09.

Who should be counted in Census 2001?
Every person young or old in South Africa on census night, 9 -- 10 October, should be counted in the household where s/he spent the night. Include non-citizens and visitors if they spent census night in the household.
Include: Babies born before midnight between 9 -- 10 October and household members who died after midnight between 9 -- 10 October 2001 as alive. (Census records the situation as at midnight between 9 -- 10 October as the reference point). Members of the household who are absent overnight, for example working, travelling or at an entertainment venue, are to be counted in the household if they return to it the next day, i.e. 10 October. Persons who stayed in institutions on census night are counted in those places. Domestic workers are counted as a separate household even if they live in the same household as the employer.

How to fill in the questionnaire
Write the codes in the appropriate boxes or dot the box.
Use a pencil. If you make a mistake, use a soft rubber to erase wrong dots, numbers or letters and write the correct answer.
Please write dots, numbers and letters clearly so that the scanning machine can read them. Always use capital letters.
For example, for a grandchild of head/acting head of household, write code [0] [9] in the box in column P-04 on the relevant line.
Make sure that all dots, numbers and letters stay inside the box.
[The original form gives an example of a dot entirely inside of a box and a dot partially inside/partially outside of a box. The dot entirely inside of the box is labeled as the correct version; the other is labeled as the incorrect version.]
For example
[1] [2] [3] [4] [5]
[6] [7] [8] [9] [10]
Do not leave spaces or use hyphens. For example, Cape Town should be written in this way:
[C] [A] [P] [E] [T] [O]
[W] [N] [ ] [ ] [ ] [ ]
Should you encounter any difficulties in the completion of the questionnaire, please contact ____ on ____ or phone the census hotline, toll free, on 0800 110248

A1

Section A: Information for persons in the household -- ask of everyone
[Section A of this form, each question has 10 answer rows for writing individual answers for up to 10 individuals in the household. Only the first is shown here, which is exactly the same as the other nine.]

P-00. Name

Please write the name and surname of the household head and first names of every person who was present in this household on the night between 9 -- 10 October.
One name on each row. Start with head or acting head of household. The head or acting head is the person who is the main decision-maker in the household. If people are equally decision-makers, take the oldest person. For babies with no name, write BABY.
____ Name
_ _ Age
_ Sex
Have you included babies, small children, old people and visitors who were present in this household on the night between 9 -- 10 October.

P-01. Person no

Assign row or person number to each person starting from 01. For example, first person becomes [0] 1, the tenth person becomes [1] 0. The eleventh person becomes [1] 1 in the second questionnaire (if used).
_ 1
_ 2
_ 3
_ 4
_ 5
_ 6
_ 7
_ 8
_ 9
_ 0
[In P-01 above, all 10 rows are listed because they are not exactly the same.]

P-02. Date of birth

What is (the person's) date of birth and age in completed years? If date of birth not known give (the person's) age in completed years. If age not known give an estimate of age.
_ _ _ _ _ _ _ _ Date of Birth
_ _ _ Age
Date of birth is recorded as DD/MM/YYYY. DD is for day / MM is for month and / YYYY is for year. For example, if the person was born on 7 September 1963, write [0] [7] for the day DD, [0] [9] for the month MM, and [1] [9] [6] [3] for the year YYYY.
For babies less than one year write [0] [0] [0] for the age, and for persons 7 years and 10 months old write [0] [0] [7] for age.

P-03. Sex

Is (the person) male or female? Dot the appropriate box.
[] M = Male
[] F = Female

P-04. Relationship

_ _ What is (the person's) relationship to the head or acting head of the household? The head or acting head is the person listed in row 1 (of the first questionnaire, if more than one questionnaire has been completed for this household). See definition of head in column P-00. Write the appropriate code in the boxes.
01 = Head/acting head
02 = Husband/wife/partner
03 = Son/daughter
04 = Adopted child
05 = Stepchild
06 = Brother/sister
07 = Parent
08 = Parent-in-law
09 = Grand/greatgrand child
10 = Son/daughter-in-law
11 = Brother/sister-in-law
12 = Other relative
13 = Non related person

A2

P-05. Marital status

_ What is (the person's) present marital status? Write only one code per person in the box. If both civil/religious and traditional marriage, indicate civil/religious.
1 = Married civil/religious
2 = Married traditional/customary
3 = Polygamous marriage
4 = Living together like married partners
5 = Never married
6 = Widower/widow
7 = Separated
8 = Divorced
If categories 5-8 go to (P-06).

P-05a. Spouse (If categories 1-4 in P-05)

_ _ Who, in the household, is (the person's) spouse or partner?
Write the person number of the spouse or partner in the appropriate box. For example, if the spouse of the head of the household is the person listed in row 2 write [0] [2] in row 1. If a man has more than one wife, write the row number of the first wife. Write the row number of the husband for each of his wives. If spouse is not in the household write [9] [9].

P-06. Population group

_ How would (the person) describe him/herself in terms of population group?
1 = Black African
2 = Coloured
3 = Indian or Asian
4 = White
5 = Other (specify) _ _ _ _ _ _ _

P-07. Language

_ _ Which language does (the person) speak most often in this household? Write only one code per person.
01 = Afrikaans
02 = English
03 = IsiNdebele
04 = IsiXhosa
05 = IsiZulu
06 = Sepedi
07 = Sesotho
08 = Setswana
09 = SiSwati
10 = Tshivenda
11 = Xitsonga
12 = Other (specify) _ _ _ _ _ _ _ _ _

P-08. Religion

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What is (the person's) religion, denomination, or belief? Please write the complete name. For example, Apostolic Faith Mission, Dutch Reformed Church, Hinduism, Islam, Zion Christian Church. If no religion, write none. Use capital letters only.

A3

P-09. Born in SA?

Was (the person) born in South Africa? Include former "homelands" as South Africa. Dot the appropriate box.
[] Y = Yes
[] N = No
If no go to P-09b

P-09a. Place of birth (If yes to P-09)

_ In which province was (the person) born?
1 = Western Cape
2 = Eastern Cape
3 = Northern Cape
4 = Free State
5 = KwaZulu-Natal
6 = North West
7 = Gauteng
8 = Mpumalanga
9 = Northern Province
Go to P-10

P-09b. Country of birth (If no to P-09)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ In which country was (the person) born? Write the present name of the country. Use capital letters only.

Citizenship

P-10. Is (the person) a South African citizen? Dot the appropriate box.
[] Y = Yes
[] N = No
If yes go to P-11
P-10a. _ _ _ _ _ _ _ _ _ _ _ _ _ _ If no, what is the name of the country of citizenship?
Use capital letters only.

Usually live

P-11. Does (the person) usually live in this household for at least four nights a week?
Dot the appropriate box.
[] Y = Yes
[] N = No
If yes go to P-12
P-11a. If no, where does (the person) usually live? If in the same place as the place of
enumeration, dot the S box.
[] S
If not the same place, write the province [P] [R], main place (city, town, tribal area, administrative area) and sub-place (suburb, ward, village, farm, informal settlement). If another country, write the name of the country in the boxes below. Use capital letters only.
_ _ Province
_ _ _ _ _ _ _ _ _ _ _ Main Place
_ _ _ _ _ _ _ _ _ _ _ Sub-space

A4

P-12. Five years ago

Five years ago (at the time of Census '96), was (the person) living in this place (i.e. this suburb, ward, village, farm, informal settlement)? Dot the appropriate box.
[] Y = Yes
[] N = No
[] B = Born after October 1996
If Y or B go to P-13

P-12a. From where moved (If no to P-12)

Where did (the person) move from? If more than one move, give details of the last move. Write the province [P] [R], main place (city, town, tribal area, administrative area) and sub-place (suburb, ward, village, farm, informal settlement). If another country, write the name of the country. Use capital letters only.
_ _ Province
_ _ _ _ _ _ _ _ _ _ Main Place
_ _ _ _ _ _ _ _ _ _ Sub-place

P-12b. In which year (If no to P-12)

_ In which year did (the person) move to this place? If more than one move, write the code for the year of the last move.
1 = 1996
2 = 1997
3 = 1998
4 = 1999
5 = 2000
6 = 2001

P-13. Disability

Does (the person) have any serious disability that prevents his/her full participation in life activities (such as education, work, social life)? Mark any that apply. Dot the appropriate boxes.
[] 0 = None
[] 1 = Sight (blind/severe visual limitation)
[] 2 = Hearing (deaf, profoundly hard of hearing)
[] 3 = Communication (speech impairment)
[] 4 = Physical (e.g. needs wheelchair, crutches or prosthesis; limb, hand usage limitations)
[] 5 = Intellectual (serious difficulties in learning)
[] 6 = Emotional (behavioural, psychological)

Mother alive

P-14. Is (the person's) own biological mother still alive? Dot the appropriate box.
[] Y = Yes
[] N = No
[] D = Do not know
P-14a. _ _ (Person no.) If yes, who in this household is (the person's) mother? For
example, if the mother is the person listed in row 2, write [0] [2]. If the mother
does not live in this household, write [9] [9] in the appropriate boxes.

A5

Father alive

P-15. Is (the person's) own biological father still alive?
[] Y = Yes
[] N = No
[] D = Do not know
P-15a. _ _ (Person no.) If yes, who in this household is (the person's) father? For
example, if the father is the person listed in row 2, write [0] [2]. If the father does
not live in this household, write [9] [9] in the appropriate boxes.

Present school attendance

P-16. _ Does (the person) presently attend an educational institution? Please include
studies by correspondence/ distance education.
1 = No (Go to P-17)
2 = Yes: Pre-school
3 = Yes: School
4 = Yes: College
5 = Yes: Technikon
6 = Yes: University
7 = Yes: Adult education centre
8 = Yes: Other (specify) _ _ _ _ _ _ _ _
P-16a. _ If yes, is this institution public or private?
1 = public (government)
2 = private
3 = don't know

[Ask of] ALL aged 5 years or more

P-17. Level of education

_ _ What is the highest level of education that (the person) has completed?
99 = No schooling
00 = Grade 0
01 = Grade 1/Sub A
02 = Grade 2/Sub B
03 = Grade 3/Standard 1
04 = Grade 4/Standard 2
05 = Grade 5/Standard 3
06 = Grade 6/Standard 4
07 = Grade 7/Standard 5
08 = Grade8/Standard 6/Form 1
09 = Grade9/Standard 7/Form 2
10 = Grade 10/Standard 8/Form 3/NTCI
11 = Grade 11/Standard 9/Form 4/NTCII
12 = Grade 12/Standard10/Form 5/Matric./NTCIII
13 = Certificate with less than Grade 12
14 = Diploma with less than Grade 12
15 = Certificate with Grade 12
16 = Diploma with Grade 12
17 = Bachelors Degree
18 = Bachelors Degree and Diploma
19 = Honours degree
20 = Higher Degree (Masters, Doctorate)
21 = Other
22 = Don't know
If categories 99 or 00-12 go to P-18

[Ask of] all persons with post-school qualifications

P-17a. Field of education (If categories 13-20 in P-17)

_ _ In which field is (the person's) highest post-school qualification?
01 = Agriculture or Renewable Natural Resources
02 = Architecture or Environmental Design
03 = Arts, Visual or Performing
04 = Business, Commerce or Management Sciences
05 = Communication
06 = Computer Science or Data Processing
07 = Education, Training or Development
08 = Engineering or Engineering Technology
09 = Health Care or Health Sciences
10 = Home Economics
11 = Industrial Arts, Trades or Technology
12 = Languages, Linguistics or Literature
13 = Law
14 = Libraries or Museums
15 = Life Sciences or Physical Sciences
16 = Mathematical Sciences
17 = Military Sciences
18 = Philosophy, Religion or Theology
19 = Physical Education or Leisure
20 = Psychology
21 = Public Administration or Social Services
22 = Social Sciences or Social Studies
23 = Other (Specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A6

Ask for all persons aged 10 years and older (born before 10 October 1991)

P-18. Any work in the 7 days before 10 October

_ In the seven days before 10 October did (the person) do any work for PAY (in cash or in kind profit or family gain, for one hour or more?
1 = Yes: formal registered (non-farming)
2 = Yes: informal unregistered (non-farming)
3 = Yes: farming
4 = Yes: has work but was temporarily absent
5 = No: did not have work
If yes go to P-19

Did not have any work

P-18a. Reason why not working (If no to P-18)

_ What is the main reason why (the person) did not have work in the seven days before 10 October? If more than one reason, write the code of the main (most important) reason.
1 = Scholar or student
2 = Home-maker or housewife
3 = Pensioner or retired person/ too old to work
4 = Unable to work due to illness or disability
5 = Seasonal worker not working presently
6 = Does not choose to work
7 = Could not find work

P-18b. Active steps (If no to P-18)

In the past four weeks before 10 October has (the person) taken active steps to find employment? For example, (the person) went to visit factories or other employment places, placed or answered advertisements, looked for land or a building or equipment to start own business or farm.
[] Y = Yes
[] N = No

P-18c. Availability (If NO to P-18)

_ If offered work, how soon could (the person) start?
1 = Within one week
2 = More than 1 week, up to 2 weeks
3 = More than 2 weeks, up to 4 weeks
4 = Some time after 4 weeks
5 = Does not choose to work
Go to P-20

Had work

P-19. Work status (If YES to P-18)

_ How can one best describe (the person's) main activity or work status?
1 = Paid employee
2 = Paid family worker
3 = Self-employed
4 = Employer
5 = Unpaid family worker
6 = Other (specify) _ _ _ _ _ _ _ _ _ _

P-19a. Business/company name (If yes to P-18)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What is the full name of the business/company or organization for whom (the person) works?
If the person works for him/herself, and the business does not have a name, write self in the appropriate row. If doing paid domestic work in a private household, write domestic service. Use capital letters only.

A7

Ask for all persons aged 10 years and older (born before 10 October 1991) who had work

P-19b. Company/business activity (If yes to P-18)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What does the business do (main economic activity)?
Write the main industry, economic activity, product or service of (the person's) employer or company. For example, gold mining, road construction, supermarket, police service, healthcare, hairdressing, banking. Or, write the activity of the person if self-employed, for example, subsistence farming. If doing paid domestic work in a private household, write domestic service. Use capital letters only.

P-19c. Occupation (If yes to P-18)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What is the main occupation of (the person) in this workplace?
Occupation refers to the type of work (the person) performed in the seven days before 10 October. Use two or more words. For example, street trader, cattle farmer, primary school teacher, domestic worker, fruit vendor, truck driver, warehouse manager, filing clerk, etc. Use capital letters only.

P-19d. Hours worked (If yes to P-18)

_ _ How many hours did (the person) work in the seven days before 10 October? If (the person) was absent from work those seven days, but usually works, write the number of hours s/he usually works.

Place of work (If yes to P-18)

(P-19e) Does (the person) work in the same sub-place in which s/he usually lives? Dot
the appropriate box.
[] Y = Yes
[] N = No

(P-19f) If no, where is this place of work? If not the same place, write province [P] [R],
main place (city, town, tribal area, administrative area) and sub-place (suburb, ward, village, farm, informal settlement). If another country, write the name of the country in the boxes below.
_ _ Province
_ _ _ _ _ _ _ _ _ _ Main Place
_ _ _ _ _ _ _ _ _ _ Sub-place

A8

Ask of women aged between 12 and 50 years (born between 1951 and 1989)

P-20. Total births

If none write [0] [0] and go to P-21. Include ALL her children, i.e. those who are still living, whether or not they live in this household, and those who are dead. Do not count stillbirths (children born dead).
[Example given of total children: 03 for total, 02 for boys and 01 for girls.]
_ _ How many [total] children, if any, has (the person) ever had, that were born alive?
_ _ How many of these were boys?
_ _ How many of these were girls?

P-20a. Still living

If the person has ever given live birth:
_ _ How many [total] children, are still alive?
_ _ How many boys are still alive?
_ _ How many girls are still alive?
For example, if 2 children of the 3 given in P-20 are still alive, 1 boy and 1 girl, write:
[Example shows 02 for total, 01 for boys and 01 for girls.]

A9

P-20b. Last child born

Write the day, month and year of the last live birth and dot the appropriate box of the sex. If multiple birth, indicate only the last child. Dot the appropriate box whether the child is still alive on Census night 9 -- 10 October. Do not count stillbirths (children born dead).
If (the person) has ever given live birth: When was (the person's) last child born?
_ _ _ _ _ _ _ _ Date of birth (DD/MM/YYYY)
What is the sex of that child?
[] M = Male
[] F = Female
Is that child alive or dead?
[] A = Alive
[] D = Dead

Ask of everyone

P-21. Travel to school or place of work

_ How does (the person) usually travel to school or to his/her place of work? Indicate the main mode of travel even if s/he was temporarily absent that week. If more than one mode of travel, write the code of the mode that covers the longest distance.
0 = Not applicable
1 = On foot
2 = By bicycle
3 = By motorcycle
4 = By car as a driver
5 = By car as a passenger
6 = By minibus/ taxi
7 = By bus
8 = By train
9 = Other

P-22. Income category

_ _ What is the income category that best describes the gross income of (this person) before tax? Choose from the table below the code that corresponds to the income level. A monthly income of R1 500 is code 04 and an annual income of R25 000 is code 05.
Monthly
01 = No income
02 = R 1 -- R 400
03 = R 401 -- R 800
04 = R 801 -- R 1 600
05 = R 1 601 -- R 3 200
06 = R 3 201 -- R 6 400
07 = R 6 401 -- R 12 800
08 = R 12 801 -- R 25 600
09 = R 25 601 -- R 51 200
10 = R 51 201 -- R 102 400
11 = R 102 401 -- R 204 800
12 = R 204 801 or more
Annual
01 = No income
02 = R 1 -- R 4 800
03 = R 4 801 -- R 9 600
04 = R 9 601 -- R 19 200
05 = R 19 201 -- R 38 400
06 = R 38 401 -- R 76 800
07 = R 76 801 -- R 153 600
08 = R 153 601 -- R 307 200
09 = R 307 201 -- R 614 400
10 = R 614 401 -- R 1 228 800
11 = R 1 228 801 -- R 2 457 600
12 = R 2 457 601 or more

A10

Section B: Information on housing

H-23. Type of living quarters

_ What is the type of these living quarters?
1 = Housing unit
2 = Residential hotel
3 = Students' residence
4 = Home for the aged
5 = Workers' hostel
6 = Other (specify) _ _ _ _ _ _ _ _ _ _ _ _
If 2-5 go to H-25

H-23a. Type of housing unit

_ _ Which type of dwelling or housing unit does this household occupy? If this household lives in more than one dwelling, write the code of the main dwelling that the household occupies in the boxes.
01 = House or brick structure on a separate stand or yard
02 = Traditional dwelling/hut/structure made of traditional materials
03 = Flat in block of flats
04 = Town/cluster/semi-detached house (simplex, duplex, triplex)
05 = House/flat/room in back yard
06 = Informal dwelling/shack in back yard
07 = Informal dwelling/shack NOT in back yard, e.g. in an informal/squatter settlement
08 = Room/flatlet not in back yard but on a shared property
09 = Caravan or tent
10 = Private ship/boat
11 = Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

H-23b. More than one dwelling

Does this household occupy more than one dwelling on this site? Dot the appropriate box.
[] Y = Yes
[] N = No

H-24. Rooms

_ _ How many rooms, including kitchens, are there for this household? Count all rooms in all dwellings. Exclude bathrooms, sheds, garages, stables, etc. unless persons are living in them. For example, if 4 rooms [0] [4].

H-24a. Sharing 1 room

If one room only: Are there two or more households sharing a single room? Dot the appropriate box.
[] Y = Yes
[] N = No

H-25. Tenure status

_ What is the tenure status of the household? If the household uses several dwellings, write the code for the main dwelling in the box.
1= Owned and fully paid off
2 = Owned but not yet paid off
3 = Rented
4 = Occupied rent-free
5 = Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

H-26. Piped water

_ In which way does this household obtain piped water for domestic use? Write only one code in the box.
1 = No access to piped (tap) water
2 = Piped (tap) water on community stand: distance greater than 200 m from dwelling
3 = Piped (tap) water on community stand: distance less than 200 m from dwelling
4 = Piped (tap) water inside yard
5 = Piped (tap) water inside dwelling

H-26a. Source of water

_ What is this household's main source of water for domestic use? Write only one code in the box.
1 = Regional/local water scheme (operated by a Water Service Authority or Provider)
2 = Borehole
3 = Spring
4 = Rain-water tank
5 = Dam / pool / stagnant water
6 = River/stream
7 = Water vendor
8 = Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

H-27. Toilet facility

_ What is the main type of toilet facility that is available for use by this household? Write only one code in the box.
1 = Flush toilet (connected to sewerage system)
2 = Flush toilet (with septic tank)
3 = Chemical toilet
4 = Pit latrine with ventilation (VIP)
5 = Pit latrine without ventilation
6 = Bucket latrine
7 = None

H-28. Energy/fuel

What type of energy/fuel does this household mainly use for cooking, for heating and for lighting? Write one code in each box.
Note:
-Wood (4), coal (5) and animal dung (7) cannot be used for lighting
-Candles (6) cannot be used for cooking or heating
_ Cooking
1 = Electricity
2 = Gas
3 = Paraffin
4 = Wood
5 = Coal
6 = Candles
7 = Animal dung
8 = Solar
9 = Other (specify) _ _ _ _ _ _ _ _ _ _ _
_ Heating
1 = Electricity
2 = Gas
3 = Paraffin
4 = Wood
5 = Coal
6 = Candles
7 = Animal dung
8 = Solar
9 = Other (specify) _ _ _ _ _ _ _ _ _ _ _
_ Lighting
1 = Electricity
2 = Gas
3 = Paraffin
4 = Wood
5 = Coal
6 = Candles
7 = Animal dung
8 = Solar
9 = Other (specify) _ _ _ _ _ _ _ _ _ _ _

H-29. Household goods

Does the household have any of the following (in working condition)? Dot the appropriate box for each item.
Radio
[] Y = Yes
[] N = No
Television
[] Y = Yes
[] N = No
Computer
[] Y = Yes
[] N =No
Refrigerator
[] Y = Yes
[] N = No
Telephone in the dwelling
[] Y = Yes
[] N = No
Cell-phone
[] Y = Yes
[] N = No
If yes to telephone or cellphone go to H-30

H-29a. Access to telephone (If no to "telephone" and "cell-phone" in H-28)

_ Where do members of this household mainly use a telephone? Write only one code in the box.
1 = At a neighbour nearby
2 = At a public telephone nearby
3 = At another location nearby
4 = At another location, not nearby
5 = No access to a telephone

H-30. Refuse or rubbish

_ How is the refuse or rubbish of this household mainly disposed of? Write only one code in the box.
1 = Removed by local authority at least once a week
2 = Removed by local authority less often
3 = Communal refuse dump
4 = Own refuse dump
5 = No rubbish disposal
6 = Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A11

Information regarding the household

H-31. Anybody died

Has any member of this household died in the past 12 months, i.e. between 10 October 2000 and 10 October 2001? Dot the appropriate box.
[] Y = Yes
[] N = No
_ If yes, how many? Go to H-31a.
If no, the questionnaire is completed.

[The following question has five answer rows for writing up to five deceased individuals. Only the first is shown here, which is exactly the same as the other four.]

H-31a. Deceased (If yes to H-30)

____ What was the first name of the deceased?
_ _ _ _ _ _ (MM/YYYY) What was the month and year of death? Write the month and year of death.
What is the sex of the deceased? Dot the appropriate box.
[] M = Male
[] F = Female
_ _ _ What was the age in years at death? For example, if 2 years of age write [0] [0] [2]
Did (the person) die from an accident or through violence? Dot the appropriate box.
[] M = Male
[] F = Female
If the deceased was a woman under 50 years, did (the person) die while pregnant or within six weeks after delivery? Dot the appropriate box.
[] M = Male
[] F = Female
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What is the surname of the head/acting head?

Thank you for your co-operation.

For office use

_ _ _ _ _ _ _ _ _ _ _ _ If more than 1 questionnaire was completed for this household (more than 10 persons present in this household on the night between 9 - 10 October 2001), write the barcode of the first questionnaire in the boxes below.

Enumerator's name and signature (confirming that s/he has completed or checked the questionnaire)

____ Name
____ Signature
_ _ _ _ _ _ _ _ Date

Supervisor's name and signature (to indicate that s/he has checked enumerator's work)

____ Name
____ Signature
_ _ _ _ _ _ _ _ Date

A12