1
SUSENAS
VSEN98.PMKS
REPUBLIC OF INDONESIA
CENTRAL BUREAU OF STATISTICS
LISTING OF MAIN HOUSEHOLD AND HOUSEHOLD MEMBER
(
Confidential
I. LOCATION IDENTIFICATION
01
02
03
04
05
06
07
08
09
10
11
Province
District/Municipality *)
Sub-District
Village/Village Unit*)
Area
Enumeration area number
Segment group number
Segment number
Sample code number
Sample household serial number
Village classification
01
Name of household head
02
Number of household members
03
04
Number of children aged 0 – 4 years old
Number of household members who has a
disability
Number of household members aged ≥ 21
years old and single
Urban
1
Rural
2
Least developed village
Developed village
1
2
Fill in at
CBS
II. SUMMARY
05
06. Is the household have reserved fund to buy basic
food for the next week?
Yes
1
No
2
07. Have you ever got the aid/service specific for
disability?
Yes
1
No
2
08. a. If Q.7 = 1, source of aid/service:
Government
1 Private 2
b. Type of aid/service:
Giving capital aid
1
Skill training
2
Counseling
4
Tools aid
8
Work chances
16
III. ENUMERATION PARTICULARS
01
02
Name and NIP/NMS of enumerator
Position of enumerator:
Staff of KS province 1 Mantis
Staff of KS regency 2 Partner
*) Cross out inapplicable category
03
04
Date of enumeration
Signature of enumerator
3
4
2
3
IV. HOUSEHOLD LISTING
Take the contents from List of VSEN98.K,
Block IV
Serial
Name
Age
Marital
no.
of
(Col.5)
Status
(Col.1)
house
(Col. 6)
hold
member
(Col.2)
(1)
(2)
(3)
(4)
ONLY FOR HOUSEHOLD MEMBERS AGED < 5 YEARS OLD
Is your
biological
mother
still
alive?
Yes 1
No 2
↵
Block V
(5)
Is the
mother
live in this
household
(check
VSEN98.
K Block
V, serial
number of
biological
mother)
Yes
1
No
2
↵
Block V
(6)
Is the
mother
working?
Yes 1
No 2
↵
Col. (9)
If
Col.7=1
Place of
work
(code)
If
Col.7=1
, does
the
mother
often
leave
the
children
alone?
Yes
No
(7)
(8)
1
2
Average
time
children
alone
(hours)
To whom
(usually)
the
children
entrusted?
(code)
If
col.8=2
or
col.9=2,
average
time
children
alone
(hours)
(10)
(11)
(12)
(13)
(9)
Code of column (8):
- Inside the house
- Outside the house
If
Col.8=1
or Col.
9=1 How
many
times
were the
children
alone the
previous
week
(days)
Code of column (12):
1
2
☛ If the answer is coded 1, skip the question
to Column 10.
☛ If the answer is coded 2, skip the question
to column 13
-
Father
Relative
Neighbor
Baby sitter
Servant
Day care center
1
2
3
4
5
6
4
5
V. INDIVIDUAL LISTING
Name:
Serial number:
1. Do you have a disability?
Yes 1
No 2 →skip to Q. 4 or finished for
Household member of 22-59
Years old
2. If “yes” type of disability:
Blind
1
Unemployed
8
Deft
2
Mute
4
3. Cause of disability:
Since birth
1
Accident/natural disaster
2
Illness
4
ONLY FOR HOUSEHOLD MEMBERS AGED 0-21
YEARS OLD, SINGLE, 60 YEARS AND ABOVE
4. How many pairs of clothes do you have? ……pairs
5. Frequency eating basic food in a week:………times
6. Frequency eating vegetables and fruits I a week:
……….times
7. Frequency eating side dish in a week: ………time
ONLY FOR HOUSEHOLD MEMBERS AGED 60
YEARS AND ABOVE
8. Are you a member of Community Social Organization
Yes 1
No 2 (finished)
9. If Q.8=1, type of activity:
Reading Quran 1
Burial 4
Others
16
“Arisan”
2
Sport
8
FOR HOUSEHOLD MEMBERS AGED ≥ 21 YEARS
OLD AND SINGLE
10. Is your biological father still alive?
Yes
1
No 2
11. Average of a day of household doing activity together
with the parent (in hour)
a. Watching TV
……….. hours
b. Eating together
……….. hours
c. Talking
……….. hours
Name:
Serial number:
1. Are you a disabled?
Yes 1
No 2 →skip to Q. 4 or finished for
Household member of 22-59
Years old
2. If “yes” type of disability:
Blind
1
Unemployed
8
Deft
2
Mute
4
3. Cause of disability:
Since birth
1
Accident/natural disaster
2
Illness
4
ONLY FOR HOUSEHOLD MEMBERS AGED 0-21
YEARS OLD, SINGLE, 60 YEARS AND ABOVE
4. How many pairs of clothes do you have? ……pairs
5. Frequency eating basic food in a week:………times
6. Frequency eating vegetables and fruits I a week:
……….times
7. Frequency eating side dish in a week: ………time
ONLY FOR HOUSEHOLD MEMBERS AGED 60
YEARS AND ABOVE
8. Are you a member of Community Social Organization
Yes 1
No 2 (finished)
9. If Q.8=1, type of activity:
Reading Quran 1
Burial 4
Others
16
“Arisan”
2
Sport
8
FOR HOUSEHOLD MEMBERS AGED ≥ 21 YEARS
OLD AND SINGLE
10. Is your biological father still alive?
Yes
1
No 2
11. Average of a day of household doing activity together
with the parent (in hour)
d. Watching TV
……….. hours
e. Eating together
……….. hours
f. Talking
……….. hours
6