1) PROVINCE OR PREFECTURE: ____
2) CIRCLE: ____
3) MUNICIPALITY: AUTONOMOUS CENTER/RURAL COMMUNE: ____
4) CENTER: ____
5) PRIMARY UNIT NUMBER: ____
6) SECONDARY UNIT NUMBER: ____
7) LEVEL: ____
8) HOUSEHOLD NUMBER: ____
9) HOUSEHOLD ADDRESS: ____
10) DATE OF VISIT: ____
11) INTERVIEWER'S NAME: ____
2 NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
5 PARTLY COMPLETED
6 TEMPORARILY ABSENT
7 DWELLING NOT OCCUPIED
8 OTHER (SPECIFY)
13) NEXT [illegible, but on other similar portions of the survey, this space has "visit" here] VISIT INDICATED
INTERVIEWER CODE: ____
FINAL RESULT: ____
TOTAL NO. OF VISITS: ____
OFFICE EDITED BY:
KEYED BY [CODE]: ____
1) Please give me the name of the people who are currently living in your household, starting with the head of the household, that is, the person responsible for the household?
2) RELATIONSHIP TO THE HEAD OF HOUSEHOLD*
What is his/her relationship to the head of household?
USUAL: Does (NAME) usually live here?
VISITOR: Did (NAME) sleep here last night?
Is (NAME) male or female?
6) IF AGE 15 OR MORE:
What is his/her marital status: Single, married, widowed, or divorced?
7) EDUCATION LEVEL FOR WOMEN AGE 15 YEARS OR MORE:
Has she ever been to school?
What is the highest level of school she has attended?
What is the highest grade she completed at that level?
01, 02, 03, etc.
Are there any other persons such as small children or infants that we have not listed?
In addition, are there any other people who many not be members of your family, such as domestic servants, friends, or others who usually live here?
Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
[##translator note: questions repeated through line number 30]