1
Attachment 1
SUSENAS
VSEN97.L
REPUBLIC OF INDONESIA
CENTAL BUREAU OF STATISTICS
1997. NATIONAL SOCIO ECONOMIC SURVEY
HOUSEHOLD LIST
Confidential
1
2
3
4
5
6
7
8
9
I. LOCATION IDENTIFICATION
Province
District/Municipality *)
Sub-District
Village/Village Unit*)
Area
Urban 1
Enumeration area number
Segment group number
Segment number
Susenas sample code number
Rural
2
II. SUMMARY (FROM BLOCK IV)
01. Number of household members
04. Number of household by monthly household
(column block IV)
expenditure category
Expenditure category
Number of household
(in thousand rupiah)
02. Number of criminal victim household
a. <150,000
(number of ! sign Column 10 Block IV)
b. 150,00 - 399,99
03. Number of household members who did the
trip (number of ! sign Column 11 Block
IV)
c. ≥400,00
d. Total
III. ENUMERATION PARTICULARS
Name and NIP/NMS enumerator
05
Name and NIP/NMS of supervisor
06
Position of supervisor
Position of enumerator:
Staff of KS province 1 Mantis
Staff of KS province 1 Mantis
3
Staff of KS regency 2 Partner
Staff of KS regency 2 Partner
4
03
Date of enumeration
07
Date of supervision
04
Signature of enumerator
08
Signature of supervisor
*) Cross out inapplicable category
01
02
3
4
2
3
IV. HOUSEHOLD LISTING
Segment
number
Physical
building
serial
number
Census
building
serial
number
(1)
(2)
(3)
Utilization of census building fill
in with check mark(! )
If the
If the
If the
housing
housing
census
census
census
building
building
building
is not a
is
is empty
dwelling
occupied
(4)
(5)
(6)
House
hold
serial
number
Name
of
head
of
house
hold
Num
ber of
house
hold
mem
bers
Is this
house
hold
ever
experien
cing a
criminal
act?*)
Yes !
No -
Is there
house
hold
member
who
traveled?
**)
Yes !
No -
(7)
(8)
(9)
(10)
(11)
Monthly household
expenditure category
(in thousand rupiah)
Fill with check mark (!)
< 150
150,0
≥400
0399,9
9
(12)
(13)
A. Total number this page
B. Cumulative total
previous pages
C. Cumulative total with
this page (A+B)
*) Between Dec, 1 1995 to November 30, 1996
**) Between September, 1 to November, 30, 1996, make a trip to tourism object, or stay over night at a
commercial accommodation, or distance of trip ≥ 100 km (return)
4
(14)