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Statistics South Africa: Preferred supplier of quality statistics
Census 2011

Household Questionnaire A
For statistical use only
[The first paragraph detailing the Statistics Act is omitted here.]

Enumeration Area number _ _ _ _ _ _ _ _
Province ____
Local municipality ____
Main place ____
Sub-place ____
Physical identification of the dwelling unit ________
Postal code _ _ _ _
Landline/Cell phone of enumerated household ____
Particulars of the household
Dwelling unit number _ _ _ _
Household number _ _ _
Total number of households at this dwelling _ _ _
Map reference number _ _ _ _
Listing record number _ _ _ _
Total number of persons in the household

Males _ _
Females _ _
Total _ _

Questionnaire _ _ of _ _ completed for this household.
If more than one questionnaire is used in the household, write the barcode of the first questionnaire below
_ _ _ _ _ _ _ _ _

Method of questionnaire completion
Mark the appropriate circle with an X

A fieldworker through an interview _
A household member through self-completion _

Field staff
Fieldworker ID number: _______
Signature: ____
Supervisor ID number: _______
Signature: ____

Response details
Visit number: ____
Date (actual): ____
Interview:

Start time: ____
End time: ____

Result code: _
Next visit (planned)

Date: ____
Time: ____

Result code and Response details:

1. Completed
2. Partly completed
3. Non-contact
4. Refusal
5. Unoccupied dwelling
6. Vacant dwelling
7. New dwelling under construction
8. Demolished dwelling
9. Status change

Final result code: _
Comments and full details of all non-response/ unusual circumstances: ________

Flap: Particulars of all individuals
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 and 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.
Have you included babies, small children, old people and visitors who were present in this household on the night between 9 and 10 October?

F-00 Person number
_

F-01 Person name
____

F-02 Age in completed years
_ _ _

F-03 Sex
Mark the appropriate circle with an X

1. Male
2. Female

Procedure of enumeration
Who should be the respondent?

  • The head/acting head of the household
  • In the absence of the head/acting head, any responsible adult member left in charge of the household.
  • Note: A household is a group of persons who live together, and provide themselves jointly with food or other essentials for living, or a single person who lives alone.
  • Domestic workers are counted as a separate household even if they live in the same household as the employer.
Who should be counted in this questionnaire?
  • All persons present in the household on the reference night (midnight 9 to 10 October 2011).
  • Include babies born before the reference night as well as visitors.
  • Members who died after the reference night must be counted as alive.
  • Members of the household who were absent overnight, for example working, travelling, or at an entertainment venue, religious gathering, if they returned to the household the next day.
  • Individuals in converted workers hostels, residential hotels and old age homes (depending on arrangements).

[The next paragraph giving examples of how to complete the questionnaire is omitted here.]

Section A: Demographics
Ask of everyone listed on the flap.

P-01 Date of birth
What is [the person]'s date of birth?

Day _ _
Month _ _
Year _ _ _ _

P-02 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.
Write the appropriate code in the box _

01. Head/ Acting head
02. Husband/ Wife/ Partner
03. Son/ Daughter
04. Adopted Son/ Daughter
05. Stepchild
06. Brother/ Sister
07. Parent (Mother/ Father)
08. Parent-in-law
09. Grand/ Great Grandchild
10. Son/ Daughter-in-law
11. Brother/ Sister-in-law
12. Grandmother/ Father
13. Other relative
14. Non-related person.

P-03 Marital status
Write the appropriate code in the box _

1. Married
2. Living together like married partners
3. Never married
4. Widower/Widow
5. Separated
6. Divorced
If 3-6, go to P-05

P-04 Spouse or Partner
Who is in this household is [the person]'s spouse or partner?
Write the person number of the spouse or partner in the appropriate box. If the spouse or partner does not reside in the household, write 98.
Note: refer to person on flap e.g. 02.

P-05 Population group
How would [the person] describe him/herself in terms of population group?
Write the appropriate code in the box _

1. Black African
2. Colored
3. Indian or Asian
4. White
5. Other

P-06 Language
Which two languages does [the person] speak most often in this household?
Write the appropriate code in the box.
If no other language, write 00 in the second box.

First _ _
Second _ _
01. Afrikaans
02. English
03. IsiNdebele
04. IsiXhosa
05. IsiZulu
06. Sepedi
07. Sesotho
08. Setswana
09. SiSwati
10. Tshivenda
11. Xitsonga
12. Other

Section B: Migration
Ask of everyone listed in the flap.

P-07 Province of birth
In which province was [the person] born?
Write the appropriate code in the box _

01. Western Cape
02. Eastern Cape
03. Northern Cape
04. Free State
05. Kwa-Zulu Natal
06. North West
07. Gauteng
08. Mpumalanga
09. Limpopo
10. Outside South Africa
11. Do not know
If 01-09, go to P-09

P-08 Country of birth
In which country was [the person] born?
Use capital letters only.
____

P-08a Year moved to South Africa
In which year did [the person] move to South Africa?
If moved more than once to South Africa, please indicate the year of the last move.
_ _ _ _

P-09 South African Citizenship
Is [the person] a South African citizen?
Mark the appropriate circle with an X.

1. Yes
2. No

P-10 Usual residence
Does [the person] usually live in this household at least four nights a week and has done so for the last six month?
Mark the appropriate circle with an X.

1. Yes
2. No
If 1, go to P-11

P-10a Province of usual residence
In which province does [the person] usually live?
Write the appropriate code in the box _

01. Western Cape
02. Eastern Cape
03. Northern Cape
04. Free State
05. Kwa-Zulu Natal
06. North West
07. Gauteng
08. Mpumalanga
09. Limpopo
10. Outside South Africa
11. Do not know
If 10, go to P-11

P-10b Municipality/ Magisterial district of usual residence
In which municipality or magisterial district does [the person] usually live?
Use capital letters only.
____

P-10c City/town of usual residence
In which city/ town does [the person] usually live or what is the nearest city/town?
Use capital letters only.
____

P-11 Since 2001
Has [the person] been living in this place since October 2001?
Write the appropriate code in the box _

1. Yes
2. No
3. Born after October 2001 but never moved.
4. Born after October 2001 and moved.
If 1 or 3, go to P-12

P-11a Month and year moved
When did [the person] move to this place?
Write the month and year in the appropriate boxes.
Month _ _
Year _ _ _ _

P-11b Province of previous residence
In which province did [the person] live before moving to this place?
Write the appropriate code in the box _

01. Western Cape
02. Eastern Cape
03. Northern Cape
04. Free State
05. Kwa-Zulu Natal
06. North West
07. Gauteng
08. Mpumalanga
09. Limpopo
10. Outside South Africa
11. Do not know
If 10, go to P-12

P-11c Municipality/ Magisterial district of previous residence
In which municipality or magisterial district did [the person] live before moving to this place?
Use capital letters only.
____

P-11d City/town of usual residence
In which city/ town did [the person] live before or what was the nearest city/town?
Use capital letters only.
____

Section C: General health and Functioning
Ask of everyone listed in the flap.

P-12 Health and functioning
Does [the person have difficulty in the following?
Write the appropriate code [number from 1 to 6] in the box.

_ A. Seeing even when using eye glasses
_ B. Hearing even when using a hearing aid
_ C. Communicating in his/her language (i.e. understanding others or being understood by others)
_ D. Walking or climbing stairs
_ E. Remembering or concentrating
_ F. With self-care such as washing all over, dressing, or feeding
1. No difficulty
2. Some difficulty
3. A lot of difficulty
4. Cannot do at all
5. Do not know
6. Cannot yet be determined

P-13 Assistive devices and medication
Does [the person] use any of the following?
Write the appropriate code [number from 1 to 3] in the box.

_ A. Eye glasses
_ B. Hearing aid
_ C. Walking stick or frame
_ D. A wheelchair
_ E. Chronic medication
1. Yes
2. No
3. Do not know

Section D: Parental survival and income
Ask of everyone listed on the flap.

P-14 Mother alive
Is [the person]'s own biological mother still alive?
Mark the appropriate circle with an X
If 2-3, go to P-15.

1. Yes
2. No
3. Do not know

P-14a Mother person number
Who in this household is [the person]'s biological mother?
If the person's mother does not reside in the household (not listed on the flap), write 98.
Note: Refer to person number on flap e.g. 02
_ _

P-14 Father alive
Is [the person]'s own biological father still alive?
Mark the appropriate circle with an X
If 2-3, go to P-16.

1. Yes
2. No
3. Do not know

P-14a Father person number
Who in this household is [the person]'s biological father?
If the person's father does not reside in the household (not listed on the flap), write 98.
Note: Refer to person number on flap e.g. 02
_ _

P-16 Income category
What is the income category that best describes the gross monthly income or annual income of [the person] before deductions and including all sources of income?
Gross income should include all sources of income e.g. Social grant, UIF, remittances, rentals, investments, sales or products, services, etc.

Monthly
01. No income
02. R1 - R400
03. R401 - R800
04. R801 - R1 600
05. R1 601 - R3 200
06. R3 201 - R6 400
07. R6 401 - R12 800
08. R12 801 - R25 600
09. R25 601 - R51 200
10. R51 201 - R102 400
11. R102 401 - R204 800
12. R204 801 and more
Annual
01. No income
02. R1 - R4 800
03. R4 801 - R9 600
04. R9 601 - R19 200
05. R19 201 - R38 400
06. R38 401 - R76 800
07. R76 801 - R153 600
08. R153 601 - R307 200
09. R307 201 - R614 400
10. R614 401 - R1 228 800
11. R1 228 801 - R2 457 600
12. R2 457 601 and more

Section E: Education
Ask of all persons aged 5 years and older listed on the flap.

P-17 School Attendance
Does [the person] presently attend an educational institution?
Mark the appropriate circle with an X
Attendance includes all part-time, full-time studies, whether in person or as a distance learner.
If 2-3, go to P-20.

1. Yes
2. No
3. Do no not know.

P-18 Educational institution
Which of the following educational institutions does [the person] attend?
Write the appropriate codes in the boxes _

1. Pre-school (including day care, crèche, pre-primary, ECD center)
2. School (including Grade R learners who attend a formal school)
3. Adult Basic Education and Training Learning Centre (ABET Centre)
4. Literacy classes (e.g. Kha Ri Gude, SANLI)
5. Higher Educational Institution (University/University of Technology)
6. Further Education and Training College (FET)
7. Other College
8. Home based education/home schooling

P-19 Public or private
Is the institution that [the person] attending public or private?
Mark the appropriate circle with an X.

1. Public (Government)
2. Private (Independent)
3. Do not know

P-20 Level of education
What is the highest level of education that [the person] has completed?
Read out: Diploma or certificate should have been at least six months study duration full-time or equivalent.
Write the appropriate code in the box _ _

98. No schooling
00. Grade 0
01. Grade 1/Sub A
02. Grade 2/Sub B
03. Grade 3/Std 1/ABET 1(Kha Ri Gude, SANLI)
04. Grade 4/Std 2
05. Grade 5/Std 3 / ABET 2
06. Grade 6/Std 4
07. Grade 7/Std 5 / ABET 3
If 98 or 00-07, go to P-22.
08. Grade 8/Std 6 / Form 1
09. Grade 9/Std 7/Form 2/
10. Grade 10/Std 8/Form 3
11. Grade 11/Std 9/Form 4
12. Grade 12/Std 10 /Form 5
If 08-12, go to P-23.
13. NTC I/N1/ NIC/(V) Level 2
14. NTCII/N2/ NIC/(V) Level 3
15. NTCIII/N3/NIC/(V) Level 4
16. N4/NTC 4
17. N5/NTC 5
18. N6/NTC 6
19. Certificate with less than Grade 12/ Std10
20. Diploma with less than Grade 12/Std 10
21. Certificate with Grade 12/Std 10
22. Diploma with Grade 12/Std 10
23. Higher Diploma
24. Post Higher Diploma (Masters, Doctoral Diploma)
25. Bachelor's degree
26. Bachelor's degree and Post graduate diploma
27. Honours degree
28. Higher degree (Masters/PhD)
29. Other
If 13-29, go to P-21.

P-21 Field of education
In which field is [the person’s] highest post-school qualification?
Write the appropriate code in the box _ _

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 Sciences
07. Education, Training or Development
08. Engineering or Engineering Technology
09. Health Care or Health Sciences
10. Home Economics
11. Industrial Arts, Traders 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
Further education and training fields of education
23. Management
24. Marketing
25. Information Technology and Computer Science
26. Finance, Economics and Accounting
27. Office Administration
28. Electrical Infrastructure
29. Civil Engineering and Building
30. Engineering
31. Primary Agriculture
32. Hospitality
33. Tourism
34. Safety in society
35. Mechatronics
36. Education and Development
37. Other
Any response, go to P-23.

P-22 Literacy
Does (name) have difficulty in doing any of the following?
Write the code [number from 1 to 5] in the appropriate box.

_ A. Writing his/her name
_ B. Reading (e.g. newspapers, magazines, religious books etc) in any language
_ C. Filling in a form (e.g. social grants forms)
_ D. Writing a letter in any language
_ E. Calculating/working out how much change he/she should receive when buying something
_ F. Reading road signs
1. No difficulty
2. Some difficulty
3. A lot of difficulty
4. Unable to do
5. Do not know

Section F: Employment
Ask of all persons aged 15 years and older listed on the flap.
P-23 Employment status

In the SEVEN DAYS before 10 October …
P-23a
Did [the person] work for a wage, salary, commission or any payment in kind (including paid domestic work), even if it was for only one hour?
Mark the appropriate circle with an X.
1. Yes
2. No
3. Do not know
In the SEVEN DAYS before 10 October …
P-23b
Did (name) run or do any kind of business, big or small, for herself/himself or with one or more partners, even if it was for only one hour?
Mark the appropriate circle with an X.
1. Yes
2. No
3. Do not know
In the SEVEN DAYS before 10 October …
P-23c
Did (name) help without being paid in any kind of business run by her/his household, even if it was for only one hour?
Mark the appropriate circle with an X.
1. Yes
2. No
3. Do not know
If 1 to any P-23a, P-23b, or P-23c, go to P-29a

P-24 Temporary absence from work
Even though [the person] did not do any work for pay, profit or did not help without pay in a household business in the SEVEN DAYS before 10 October, did he/she have a paid job or business that he/she would definitely return to?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 1, go to P-29a

P-25 Looking for work
In the four weeks before 10 October was [the person] looking for any kind of job or trying to start any kind of business?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 1, go to P-28

P-26 Liked to work
Would (name) have liked to work in the SEVEN DAYS before 10 October?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 2 or 3, go to P-32

P-27 Reasons for not working
What was the main reason for not trying to find work or starting a business in the last four weeks before 10 October?
Write the appropriate code in the box _ _

01. Awaiting the season for work
02. Waiting to be recalled to former job
03. Health reasons
04. Pregnancy
05. Disabled or unable to work (handicapped)
06. Housewife/homemaker (family considerations/child care)
07. Undergoing training to help find work
08. No jobs available in the area
09. Lack of money to pay for transport to look for work
10. Unable to find work requiring his/her skills
11. Lost hope of finding any kind of work
12. No transport available
13. Scholar or student
14. Retired
15. Too old/young to work
16. Did not want to work
17. Other

P-28 Available to work
If a suitable job had been offered or circumstances had allowed, would [the person] have been able to start work or a business in the SEVEN DAYS before 10 October?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
Any response, go to P-32

P-29a Industry
What is the name of [the person]'s place of work/organisation/company/business?
Examples: Komani Hospital, Rapele Primary School, Harmony Gold Mining
Use capital letters only
Do not leave spaces between words
____

P-29b Main goods or services
What are the main goods or services produced at [the person]'s place of work or its main functions?
Examples: Real Estate, Construction, Car Repairing, Hospitality Service
Use capital letters only
Do not leave spaces between words
____

P-30 Main task/ duty
What is [the person]'s main task or duty in this work?
Examples: Teaching children, Selling fruit, Bookkeeping, Feeding cattle
Use capital letters only
Do not leave spaces between words
____

P-31 Type of sector
Is [the person]'s place of work ....?
Write the appropriate code in the box.

1. In the formal sector
2. In the informal sector
3. Private household
4. Do not know

Section G: Fertility
Ask of women aged 12-50 years on the flap

P-32 Children ever born
Has [the person] ever given birth to a live child, even if the child died soon after birth?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 2 or 3, go to H-01

P-33 Age at first birth
At what age did [the person] have their first born child?
_ _

P-34 Total children ever born
How many children has [the person] ever had that were born alive?
_ _

P-35 Total surviving and living in the household
How many of [the person's] children are still alive and living with her in this household, including grown-ups?
_ _

P-36 Total surviving and living elsewhere
How many of [the person's] children are still alive and living elsewhere, including grown-ups?
_ _

P-37 Total children no longer alive
How many of [the person's] children are no longer alive?
_ _

P-38 Last child born
When was [the person's] last child born, even if the child died soon after birth?
_ _

P-39 Sex of last child born
Is [the person's] last child born male or female?
Mark the appropriate circle with an X.

1. Male
2. Female
3. Do not know

P-40 Last child born alive
Is [the person's] last child born still alive?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 1 or 3, go to H-01

P-41 Date of death of the last child born
When did [the person's] last child born die?

Day _ _
Month _ _
Year _ _ _ _

Section H: Housing, household goods and services and agricultural activities
Ask of every household

H-01 Type of living quarters
What is the type of these living quarters?
Write the appropriate code in the box _

1. Housing unit
2. Residential Hotel
3. Home for the aged
4. Converted hostel
5. Other
If 2-4, Go to H-07
[Question H-01 through M-05 were asked of households in housing units or converted hostels]
Type of main dwelling
Which of the following best describes the main dwelling and other dwelling(s) that this household occupies?
Write the appropriate code in the boxes.

Main dwelling _ _
Other dwelling _ _
01. House or brick/concrete block structure on a separate stand or yard or on a farm
02. Traditional dwelling/hut/structure made of traditional materials
03. Flat or apartment in a block of flats
04. Cluster house in complex
05. Townhouse (semi-detached house in a complex)
06. Semi-detached house
07. House/flat/room in backyard
08. Informal dwelling/shack in backyard
09. Informal dwelling/shack not in backyard, e.g. in an informal/squatter settlement or on a farm
10. Room/flatlet on a property or a larger dwelling/servants’ quarters/granny flat
11. Caravan/tent
12. Other

H-02a Construction material
What is the main material used for the construction of the roof and wall of the MAIN dwelling?
Write the appropriate code in the boxes.

Roof _ _
Wall _ _
01. Brick
02. Cement block/Concrete
03. Corrugated iron/zinc
04. Wood
05. Plastic
06. Cardboard
07. Mud and cement mix
08. Wattle and daub
09. Tile
10. Mud
11. Thatch/Grass
12. Asbestos
13. Other

H-03 Rooms
How many rooms are there in the main dwelling of this household?
Write the appropriate codes in the boxes

Dining rooms _ _
Living rooms _ _
Dining/Living room _ _
Bedrooms _ _
Study rooms _ _
One room with multiple uses _ _
Other rooms _ _
Total rooms _ _
Exclude bathrooms and kitchen.
Include garages if some members of the household are living in them.

H-04 Tenure status
What is the tenure status of this household?
Write the appropriate codes in the boxes _

1. Rented
2. Owned but not yet paid off
3. Occupied rent-free
4. Owned and fully paid off
5. Other

Refers to the main dwelling structure only and not to the land that it is situated on.

H-05 Estimated value of property
What would you estimate the market value or municipal valuation of this property to be?
Write the appropriate codes in the boxes _

1. Less than R50 000
2. R50 001 – R100 000
3. R100 001 – R200 000
4. R200 001 – R400 000
5. R400 001 – R800 000
6. R800 001 – R1 600 000
7. R1 600 001 – R3 200 000
8. More than R3 200 001
9. Do not know

H-06 Age of the property
What is the age of this dwelling?
Write the appropriate codes in the boxes _

01. Less than one year
02. 1 - 5 years
03. 6 - 10 years
04. 11 - 20 years
05. 21 - 30 years
06. 31 - 40 years
07. 41 - 50 years
08. 51 - 60 years
09. 61 years or older
10. Do not know

The age of the dwelling refers to when the building was completed, not the time of any later remodeling, additions or conversions.
If the actual age is not known, give the best estimate.

H-07 Access to piped water
In which way does this household mainly get piped water for household use?
Write the appropriate codes in the boxes _

1. Piped (tap) water inside the dwelling
2. Piped (tap) water inside the yard
3. Piped (tap) water on community stand: distance less than 200m from dwelling
4. Piped (tap) water on community stand: distance between 200m and 500m from dwelling
5. Piped (tap) water on community stand: distance between 500m and 1000m (1 km) from dwelling
6. Piped (tap) water on community stand: distance greater than 1000m (1 km) from dwelling
7. No access to piped water

H-08 Source of water
What is this household’s main source of water for household use?
Write the appropriate codes in the boxes _

1. Regional/local water scheme (operated by municipality or other water services provider)
2. Borehole
3. Spring
4. Rain water tank
5. Dam/pool/stagnant water
6. River/stream
7. Water vendor
8. Water tanker
9. Other
If 2-9, Go to H-10

H-09 Reliability of water supply
In the last 12 months, has this household had any interruptions in piped water supply?
Mark the appropriate circle with an X.

1. Yes
2. No
If 2, Go to H-10

H-09a Reliability of water supply
Did any specific interruption(s) in piped water supply last longer than two days?
Mark the appropriate circle with an X.

1. Yes
2. No
If 2, Go to H-10

H-09b Alternative water source
What alternative water source did the household use during water supply interruption?
Write the appropriate codes in the boxes _

1. Borehole
2. Spring
3. Rain water tank
4. Dam/pool/stagnant water
5. River/stream
6. Water vendor
7. Water tanker
8. Other
0. None

H-10 Toilet facilities
What is the main type of toilet facility used by this household?
Write the appropriate codes in the boxes _

1. Flush toilet (connected to sewerage system)
2. Flush toilet (with septic tank)
3. Chemical toilet
4. Pit toilet with ventilation (VIP)
5. Pit toilet without ventilation
6. Bucket toilet
7. Other
0. None

H-11 Energy/fuel
What type of energy/fuel does this household mainly use for cooking, heating and lighting?
Write the appropriate code in the box.

Cooking _
Heating _
Lighting _
1. Electricity
2. Gas
3. Paraffin
4. Wood
5. Coal
6. Candles
7. Animal dung
8. Solar
9. Other
0. None
Note:
  • Wood (4), coal (5) and animal dung (7) cannot be used for lighting
  • Candles (6) cannot be used for heating or cooking

H-12 Refuse disposal
How is the refuse or rubbish from this household mainly disposed of?
Write the appropriate codes in the boxes _

1. Removed by local authority/private company at least once a week
2. Removed by local authority/private company less often
3. Communal refuse dump
4. Own refuse dump
5. No rubbish disposal
6. Other

H-13 Household goods and services
Does this household own any of the following in working order?
Write the appropriate codes in the boxes

1. Yes
2. No
_ Refrigerator
_ Electric/gas stove
_ Vacuum cleaner
_ Washing machine
_ Computer
_ Music center
_ DVD Player
_ Motorcar
_ Television
_ Radio
_ Landline/Telephone
_ Cell phone
_ Mail Post box/bag
_ Mail box at residence

H-13a Access to internet
How does this household mainly access internet?
Write the appropriate codes in the boxes _

1. From home
2. From Cell phone
3. From elsewhere other than home
4. No access to internet

H-14 Agricultural activities
What kind of agricultural activity is the household involved in?
(More than 1 activity can be chosen)
Mark the appropriate circle with an X.

1. Livestock production (cattle, goats, sheep, pigs, etc)
2. Poultry production (chicken, ducks, geese, guinea fowl, ostrich, etc)
3. Vegetable production
4. Production of other crops (grains, fruits, etc)
5. Fodder grazing/pasture/grass for animals
6. Other
0. None
If only 2-6, go to H-14b. If 0, go to M-00

H-14a Livestock
How many of the following does the household own?
Write the appropriate codes in the boxes

1. Cattle _
2. Sheep _
3. Goats _
4. Pigs _
5. Other _
A. 0
B. 1-10
C. 11-100
D. 100+

H-14b Place of agricultural activities
Where does this household operate its agricultural activities?
Mark the appropriate circle with an X.

1. Farm land
2. Backyard or school
3. Communal or tribal land
4. Other

Section I: Mortality in the last 12 months

M-00 Death occurred
Has any member of this household passed away in the last 12 months (between 9 October 2010 and 9 October 2011)?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 2 or 3, Questionnaire completed

M-00a Number of deaths
How many members of the household passed away in the last 12 months (between 9
October 2010 and 9 October 2011)?
_ _

M-01 Name of deceased
What was the first name of (the deceased)?
Use capital letters only
____

M-02 Month and year of death
What was the month and the year of (the deceased’s) death?
Write the month and year in the appropriate boxes.
Month _ _
Year _ _ _ _

M-03 Sex of the deceased
Was (the deceased) male or female?
Mark the appropriate circle with an X.

1. Male
2. Female

M-04 Age of the deceased
What was (the deceased’s) age in completed years at the time of death?
Write the age in the box. If age is less than 1 year, write 00.
_ _

M-05 Cause of death
What caused the death of (the deceased)?
Mark the appropriate circle with an X.

1. Unnatural death (e.g. violence or accident)
2. Natural death

[Question P-06 to M-08 are asked only of deceased women 12-50 years at the time of death]

M-06 Pregnant at time of death
Did (the deceased) die while pregnant?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know

M-07 Death during birth
Did (the deceased) die while giving birth?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know
If 1 to M-06 or M-07, questionnaire completed

M-08 Postnatal death
Did (the deceased) die within 6 weeks after delivery?
Mark the appropriate circle with an X.

1. Yes
2. No
3. Do not know

Questionnaire B: Transient and tourist hotel

Enumeration Area number _ _ _ _ _ _ _ _
Province ____
Local municipality ____
Main place ____
Sub-place ____
Type of place
Mark the appropriate circle with an X

_ Airport
_ Border post
_ Harbour
_ Tourist hotel
_ Other

SDI number _ _ _ _
Name of the place ____
Map reference number _ _ _ _
Listing record number _ _ _ _

Method of questionnaire completion
Mark the appropriate circle with an X

A fieldworker through an interview _
A household member through self-completion _
Field staff
Fieldworker ID number: _______
Signature: ____
Supervisor ID number: _______
Signature: ____
[The next paragraph detailing the Statistics Act is omitted here.]

Procedure of enumeration
Who should complete this questionnaire

  • All persons who will be in transit (departing) at airports, harbors, border posts, people in tourist hotels, camping sites, caravan parks, the homeless (not in a shelter) and mobile populations (midnight 9 - 10 October 2010).
  • Parents travelling with children should fill in a separate questionnaire for each child.
How to complete the questionnaire
  • Read every question carefully.
  • For questions where a choice of answers is provided, the fieldworker/respondent should write the appropriate codes in the boxes.
  • Make sure that all the codes are written inside the boxes

[Examples and administrative information is omitted here.]

F-01 What is your name / name and surname / initials?
Use capital letters only
_____

F-02 What is your age in completed years?
For babies less than 1 year write 000 for age. For persons 7 years and 10 months write 007 for age.
_ _

F-03 Are you male or female?
Mark the appropriate circle with an X.

1. Male
2. Female

P-01 What is your date of birth?

Day _ _
Month _ _
Year _ _ _ _

P-03 What is your present marital status?
Write the appropriate codes in the boxes _

1. Married
2. Living together like married partners
3. Never married
4. Widower / widow
5. Separated
6. Divorced

P-05 How would you describe yourself in terms of population group?
Write the appropriate codes in the boxes _

1. Black African
2. Colored
3. Indian or Asian
4. White
5. Other

P-07 In which province were you born?
Write the appropriate codes in the boxes _

01. Western Cape
02. Eastern Cape
03. Northern Cape
04. Free State
05. KwaZulu Natal
06. North West
07. Gauteng
08. Mpumalanga
09. Limpopo
10. Outside South Africa
If 01-09, go to P-09

P-08a If you are born outside the country, in which year did you move to South Africa?
If moved more than once into South Africa, please indicate the year of last move.
_ _ _ _

P-09 Are you a South African citizen?
Mark the appropriate circle with an X.

1. Yes
2. No

P-10a In which province do you usually live for at least four nights a week and have done so for the last six months?
Write the appropriate codes in the boxes _ _

01. Western Cape
02. Eastern Cape
03. Northern Cape
04. Free State
05. KwaZulu Natal
06. North West
07. Gauteng
08. Mpumalanga
09. Limpopo
10. Outside South Africa
If 10, Questionnaire complete

P-10c In which city/town do you usually live or what is the nearest city/town? Use capital letters only
_______
Questionnaire C: For institution only

For statistical use only
Enumeration Area number _ _ _ _ _ _ _ _
Province ____
Local municipality ____
Main place ____
Sub-place ____

Particulars of the institution
SDI number _ _ _ _
Name of the institution ____
Block/Ward ____
Physical identification of the institution ________
Postal code _ _ _ _
Telephone number _ _ _ _ _ _ _ _ _ _
Number of persons in the institution

Total _ _ _ _
Male _ _ _
Female _ _ _

Map reference number _ _ _ _
Listing record number _ _ _ _

Procedure of enumeration
Who should be enumerated/counted on this questionnaire?

  • Individuals who will be accommodated in an institution (for example, student residences, boarding schools, frail care centers, hospitals, defense force/army barracks, police cells, prisons, unconverted hostels, shelter for the homeless/refugees/other shelters, initiation schools, convents/monasteries, orphanages, homes for the disabled and old age homes - depending on the arrangement) on reference night should be enumerated.
  • Include babies born before midnight between 9 - 10 October 2010
  • Hotel managers/administration should complete the section on services and the fieldworker to complete the other sections
  • How to complete the questionnaire
  • Read every question carefully
  • For questions where a choice of answers is provided, the fieldworker/respondent should write the appropriate codes in the boxes
  • Make sure that all the codes are written inside the boxes.

[Examples are omitted here.]
Questionnaire _ _ of _ _ completed for this institution.
If more than 250 persons in the institution, write the barcode of the 1st questionnaire below:
_ _ _ _ _ _ _ _ _

Field staff
Fieldworker ID number: _______
Signature: ____
Supervisor ID number: _______
Signature: ____

(H-01) What type of collective living quarter is this?
Write the appropriate codes in the boxes _ _

01. Hospital/medical facility/clinic
02. Prison/correctional institution/police cells
03. Defense force barracks
04. Frail care centers
05. Refugee camp/shelter
06. Covent/monastery
07. Community or church hall
08. Unconverted hostel
09. Student residence/boarding school
10. Tourist hotel
11. Other

H-07 In which way does this institution mainly get piped water for use?
Write the appropriate codes in the boxes _

1. Piped (tap) water inside the institution
2. Piped (tap) water inside the yard
3. Piped (tap) water on community stand: distance less than 200m from institution
4. Piped (tap) water on community stand: distance between 200m and 500m from institution
5. Piped (tap) water on community stand: distance between 500m and 1000m (1 km) from institution
6. Piped (tap) water on community stand: distance greater than 1000m (1 km) from institution
7. No access to piped water

H-08 What is this institution’s main source of water for domestic use?
Write the appropriate codes in the boxes _

1. Regional/local water scheme (operated by municipality or other water services provider)
2. Borehole
3. Spring
4. Rain water tank
5. Dam / pool/ stagnant water
6. River / stream
7. Water vendor
8. Water tanker
9. Other

H-10 What is the main source of toilet facility used by this institution?
Write the appropriate codes in the boxes _ _

1. Flush toilet (connected to sewerage system)
2. Flush toilet (with septic tank)
3. Chemical toilet
4. Pit toilet with ventilation (VIP)
5. Pit toilet without ventilation
6. Bucket toilet
7. Other
0. None

H-11 What type of energy/fuel does this institution mainly use for cooking, heating and lighting?
Write the appropriate codes in the boxes

Cooking _
Heating _
Lighting _
1. Electricity
2. Gas
3. Paraffin
4. Wood
5. Coal
6. Candles
7. Animal dung
8. Solar
9. Other
0. None
Note
  • Wood (4), coal (5) and animal dung (7) cannot be used for lighting
  • Candles (6) cannot be used for heating or cooking

H-12 How is the refuse or rubbish from this institution mainly disposed of?
Write the appropriate codes in the boxes _ _

1. Removed by local authority/private company at least once a week
2. Removed by local authority/private company less often
3. Communal refuse dump
4. Own refuse dump
5. No rubbish disposal
6. Other

H-13 Does this institution own any of the following in working order?
Write the appropriate codes in the boxes

1 = Yes
2 = No
Television _
Radio _
Landline telephone _
Refrigerator _
Internet facilities _

List of persons in this institution on census night

F-00 Person number
_ _ _ _

F-01 Name/Name and surname/initials
____

P-01 Date of birth

Day _ _
Month _ _
Year _ _ _ _

F-02 Age in completed years
_ _ _

F-03 Sex
Mark the appropriate circle with an X.

1. Male
2. Female

P-05 Population group
Write the appropriate codes in the boxes _

1. Black African
2. Colored
3. Indian or Asian
4. White
5. Other

P-03 Marital status
Write the appropriate codes in the boxes _

1. Married
2. Living together like married partners
3. Never married
4. Widower/Widow
5. Separated
6. Divorced

Barcode Number
Use the corresponding barcode from questionnaire B if the same person is completed in both.
_ _ _ _ _ _ _ _ _

Comments and full details of all non-response/unusual circumstances
________