1
Serial
number
of
house
hold
member
Name
of
house
hold
member
(1)
(2)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
Codes for column (3)
Head of household
Wife/husband
Children
Son/daughter in-law
Grandchildren
Parent/In-law
Relative
House maid
Relation
to the
head of
house
hold
(code)
Gender:
Male 1
Female 2
(3)
(4)
1.1 DEMOGRAPHY
Age
Marital Education
(year)
Status
ever
(code)
completed
(code)
(5)
Codes for column (6)
Single
1
Married
2
Widowed
3
Divorced
4
(6)
(7)
Codes for column (7)
No schooling
Not finished
primary school yet
Primary School
Junior high school
Vocational junior
high school
Senior high school
Vocational senior
High school
If column
(7), coded
2, Can
you read
and write
Yes
1
No
2
(8)
For 12 years only
Are you in
school?
Yes 1
No 2
If ‘No’
what is
the
reason?
(code)
(9)
(10)
Codes for column (10)
Not money
Not capable
No school available/
too far
Other
2
3
Serial
number
likes on
column
(1) block
I.1
Name of
Household
member
aged 10
years and
above
I.2. Labour Force (for 10 years old and above)
Activities
If working/not working temporarily, what is the primary activity?
during
Field of
Code
Type of
Code
Work status
previous
work
filled in work
filled in (code)
week
by CBS
by CBS
(code)
Codes for column (3):
Working/temporarily not working
Looking for a job
Attending school
Taking care of household
Retired, handicapped, etc
Codes for column (8):
1
2
3
4
5
Self employed
Self employed assisted by family members/
temporary workers
Employer with permanent workers
Employee/worker
Family worker
1
2
3
4
5
4
5
Serial
number
as per
column
(1) block
I.2
(1)
I.3. SOCIO-CULTURE: (only for aged 10 years and older)
During the previous week
During the previous
month
What kind What kind
What
What interested you in:
of cultural of
kind of
A
Type of
The radio TV
recreation
programs programs film from magazine/ sport that activity
do you
newspaper you often you’ve
movies
you
you
article that practice? ever seen often do?
watched? you’ve
listened
which
watched? you’ve
to/
interested (code)
read?
followed?
you?
(code)
(code)
(code)
(code)
(code)
(code)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Codes for column (2) and (3)
Never heard/followed/
Watched
Have heard/followed/
Watched:
News
Entertainment/art
Sport
Science program
Religious program
Others
Codes for column (4)
-1
-2
-3
-4
-5
-6
-7
Codes for column (7)
Never watched: arts
Dances
Music
Play/Theatre
Wayang
Never watched movie/
film
Have watched movie/
film:
War/History
Detective
“Silat”
Drama
Comedy
Others
Codes for column (5)
-1
-2
-3
-4
-5
-6
-7
Codes for column (8)
-1
-2
-3
-4
-5
Never go for
recreation
Watch movie
Picnic/Tourism
Sport
Others
-2
-3
-4
-5
If col. (9)
coded
“1”, what
is the
reason?
(code)
(code)
(9)
(10)
Codes for column (6)
Do not read news-1
No sports
paper/magazine
Practice sports:
Read newspaper/
Athletics
magazine:
Football (Soccer)
News
-2
Badminton
Science column
-3
Volleyball
Editorial
-4Others
-6
Sports column
-5
Arts and culture
-6
Codes for column (9)
-1
Are you a
member
of a social
organizati
on?
Not a member of any
Soc. Organization
A member of org.:
Youth
Art/Sport
Burial
Others
-1
-2
-3
-4
-5
Codes for column (10)
-1
-2
-3
-4
-5
Lazy/reluctant
No use
Afraid
Others
-1
-2
-3
-4
6
7
I.4. ENVIRONMENT AND HEALTH
1. Nearest distance from home to:
a. Market: …………………… km
b. Cinema: ………………… km
c. Amusement Park: ………... km
d. Primary School: ………… km
e. Junior High School: ……… km
f. Senior High School: …….. km
2. a. Land area (including the building)
: …………….. m2
b. Floor area
: …………….. m2
3. a. Number of rooms:
:……………. Rooms
b. Number of bedrooms:
:……………. Rooms
4. a. Do you have windows?
:Yes
-1
No
-2
b. If “yes”, how many
:……………….windows
c. If ‘not”, is there ventilation?
:Yes
1
No
-2
5. Bathroom:
Private -1
Shared
-2
Public
-3
Others
-4
6. Washing area:
Private -1
Shared
-2
Public
-3
Others
-4
7. Drying area:
In a room in the house
1
In the yard
3
In the open air in the house 2
Others
4
8. a. Toilet:
Private
1
Shared
2
Public
3
Others
4
b. If you have private or shared toilet, do you have:
Septic tank
1
No septic tank
2
9. a. Drinking water facility:
Pipe
1
Well
3
River
5
Other
7
Pump
2
Spring
4
Rain water 6
b. If you have pump or well, distance of source of water to the cesspool:
(5 m)
-1
(5 – 9 m)
-2
(10 – 14 m) -3
(≥ 15 m)
-4
10.Kitchen:
Private
-1
Shared -2
Public -3
Others -4
11.a. Do you have livestock cage? Yes
-1
No
-2
b. If “yes”, location of cage:
In the house
-1
Outside the house
-2
12.Water situation in gutter/river around the house:
Stagnant 1
Flows slowly
2
Flows quickly
3
13.a. Are there any household members who were ill during the previous week?:
Yes -1
No
-2
b. If “yes”, fill in this following table:
Have you
Type of
Duration
Where did Distance
Serial
Name of
you go for to place of ever been
household number of Illness (1) of illness
treatment: treated?
treatment
household (code)
member
(km)
Yes
-1
(2)
member
who has
No
-2
(code)
likes col.
sick
I.1
(1)
(2)
(3)
(4)
(5)
(6)
(7)
a.
c.
e.
b.
d.
f.
If “yes”,
where?(3)
(code)
(8)
8
I.4. ENVIRONMENT AND HEALTH (continued)
13.c. If “not”, were there any members who were ill three months ago?:
Yes -1
No
-2
d. If “yes”, fill in this following table:
Duration
Where did Distance
Serial number Type of
Name of
you go for to place of
illness (1)
of household
household
treatment:
treatment
(code)
member who member likes
(km)
(2)
col. I.1
has sick
(code)
(1)
(2)
(3)
(4)
(5)
(6)
14.a. Were there any births during the previous year? Yes
b. If “yes”, fill in this following table:
Place of birth
Serial number of
Name of
(code) (4)
household member
person who
as per col. I.1
gave birth
(1)
(2)
(3)
1
No
(1)
Codes:
(1) Illness
TB/lounge
Diarrhea & vomitting
Malaria
Internal disease
Others
(5) Birth attendant
Medical doctor
Midwife or other
Paramedics
Trad, Birth attendant
Others
(2)
1
2
3
4
5
1
2
3
4
4
3 Trad. Birth attendant 5
Others
6
No
Gender:
Male
Female
1
2
(6)
3 Others
2
Cause of death:
(code) (6)
1
2
(3)
(2) Medical Treatment location
Doctor’s practice
1
Hospital
2
Puekesmas
3
Clinic
4
Paramedics
5
Traditional healer
6
Own medication
7
Not have medication
8
(6) Cause of death:
Accident
Diarrhea & vomitting
Heart disease
Others
1
Born alive
Still birth
(5)
c. During the pregnancy, did the mother get routine pregnancy examinations?
Yes
1
No
2
d. If “yes” who is examined her?
Medical doctor 1 Midwife
2
Traditional Birth Attendant
e. After give birth, did she have her baby examined regularly?
Yes
1
No
2
f. If “yes”, where did she take the baby?
At doctor’s/midwife’s practice
1 Hospital/maternity clinic/BKIA
Puskesmas
2
Public hospital
4
15.a. Were there any deaths during the previous month? Yes
b. If “yes”, fill in this following table:
Name of deceased
Aged when passed away
(year)
(8)
2
Birth attendant
(code) (5)
Distance to the
place of give
birth (km)
(4)
If “yes”, where
did you go?(3)
(code)
Have you
ever been
treated?
Yes
-1
No
-2
(7)
(3) Place of treatment:
Puskesmas
Hospital
Clinic/BKIA
At health paramedics
house
At traditional
healer’s house
Other
(4)
1
2
3
4
5
6
(4) Place birth:
Maternity hospital includes:
Maternity clinic
1
Public hospital
2
Puskesmas
3
At doctor’s/midwife’s
4
practice
At traditional birth
5
attendant’s house
Own house
6
Others
7
1
2
3
4
9
10
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Share/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
A. Cereals
001 Imported rice
kg
002 Best quality rice
Kg
003 Local rice
Kg
004 Sticky rice
Kg
005 Rice products
Kg
006 Wet corn with
Kg
skin
007 Dried corn with ski
Kg
008 Dry, shelled corn
Kg
009 Corn flour (ex
Kg
maizena)
010 Wheat flour
Kg
011 Other
012 Sub-total A
Ser Detail
ial
num
ber
013
014
015
016
017
018
019
020
021
022
B. Tubers
Cassava
Dried cassava chip
Cassava flour
Dried-cassava flour
Sweet potato
Potato
Taro
Sago (not from
cassava flour e.g.:
Ambon sago)
Other
Sub-total B
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
kg
11
12
Ser Detail
ial
num
ber
(1)
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
023
024
025
026
027
028
029
C. Fish
1) Fresh sea water
fish
Bandeng/milkfish
Yellow tail
Tuna
Cakalang/skipjack
Selar/mackerel
Teri
Others
Kg
Kg
Kg
Kg
Kg
Kg
Kg
030
031
032
033
2) Fresh water fish
Gabus
Tilapia
Gold fish
Others
Kg
Kg
Kg
Kg
034
035
036
037
038
039
3) Dried fish/salted
fish
Peda
Teri
Selar
Shrimp
Squid
Others
Ounce
Ounce
Ounce
Ounce
Ounce
Ounce
040
4) Canned Fish
Canned fish
Kg
041
042
043
5) Shrimp
Shrimp
Squid
Crab
Kg
Kg
Kg
044
045
6) Others
Others
Sub-total C
13
14
Ser Detail
ial
num
ber
(1)
046
047
048
049
050
051
052
053
054
055
056
057
058
059
060
061
062
063
064
065
066
067
068
069
070
071
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
D. Meat
Beef
Buffalo
Goat
Pork
Horse
Dried beef
Corned
Dried shredded
beef (abon)
Liver
Innards
Bone
Other meats
Chicken meat
Other poultry meat
Sub-total (D)
E. Milk and Egg
Chicken egg
Duck egg
Salted egg
Others egg
Pure milk
Factory-processed
liquid milk
Sweet condensed
milk
Canned powdered
milk
Powdered milk (per
kg)
Dairy products
Sub-total (E)
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
unit
Kg
Kg
Pieces
Pieces
Pieces
Pieces
Liter
Liter
Kg
Kg
Kg
15
16
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
F. Vegetables
072 Spinach
Kg
073 Water spinach
Kg
074 Cabbage
Kg
075 Mustard greene
Kg
076 Green beans
Kg
077 String beans
Kg
078 Tomato
Kg
079 Carrot
Kg
080 Cucumber
Kg
081 Cassava leafs
Kg
082 Eggplants
Kg
083 Soya sprout
Kg
084 Squash
Kg
085 Radish
Kg
086 Complete
Package
vegetables soup
087 Complete sour soup
Package
088 Jack fruit (young)
Kg
089 Papaya (young)
Kg
090 Petai (bean with
Kg
pungent odor)
091 Jengkol (phiteco
Kg
lobium)
092 Shallot
Ounce
093 Garlic
Ounce
094 Red chili
Ounce
095 Small chili
Ounce
096 Green chili
Ounce
097 Canned vegetables
Kg
098 Other
099 Sub-total (F)
Ser Detail
ial
num
ber
17
18
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
G. Pulses
100 Peanut
Kg
101 Mung bean
Kg
102 Kidney bean
Kg
103 Soybean
Kg
104 Lima bean
Kg
105 Tofu
Kg
106 Tempe/fermented
Kg
soybean cake
107 Fermented soybean
Kg
paste
108 Oncom/fermented
Kg
soybean sediment
cake
109 Soy milk
Kg
110 Cashew nut
Ounce
111 Others
112 Sub-total (G)
Ser Detail
ial
num
ber
113
114
115
116
117
118
119
120
121
122
123
124
125
H. Fruits
Orange
Mango
Apple
Avocado
Rambutan
Lanzon
Durian
Snake fruit
Pineapple
“Ambon” banana
“Raja” banana
Other banana
Papaya
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
Kg
19
20
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
126 Sawo/sapodilla
Kg
127 Star fruit
Kg
128 Kedondong
Kg
129 Water melon
Kg
130 Jack fruit (ripe)
Kg
131 Tomato
Kg
132 Canned fruit
Kg
133 Others
134 Sub-total (II)
Ser Detail
ial
num
ber
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
I. Other
consumption
Salt
Candle nuts
Coriander/cumin
Pepper
Tamarind
Nutmeg
Clove
Vinegar
Paste shrimp
Soybean sauce
Coconut
Coconut oil
Frying oil
Corn oil
Butter
Cooking spices
(ginger, galangale,
etc)
Palm sugar
Ounce
Ounce
Ounce
Ounce
Ounce
Ounce
Ounce
CC
Ounce
CC
Unit
Liter
Liter
Liter
Ounce
Ounce
21
22
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
152 Granulated sugar
153 Tea
154 Coffee
155 Powder cocoa
156 Fish/shrimp chips
157 Emping chips
158 Noodle
159 Rice noodle
160 Macaroni
161 Monosodium
Glutamate
162 Syrup
163 Other
164 Sub-total (I)
Ser Detail
ial
num
ber
165
166
167
168
169
170
171
172
173
J. Beverages &
food
Iced Syrup
Soda pop/canned
soft drink
Biscuits
White bread
Mung bean
porridge
Gado-gado
Rice and side
dishes (nasi rames)
Others
Sub-total (J)
23
24
II. 1. CONSUMPTION OF FOOD, BEVERAGES, AND TOBACCO DURING PREVIOUS WEEK
Type/
Standard
Purchase
Own Production
Shared/gift, etc
Total consumption
quality
Unit
(cash/credit)
Quantity Value
Quantity Value
Quantity Value
Quantity Value
(5)+(7) ((6)+(8)
+ (9)
+ (10)
(0,00)
(Rp)
(0,00)
(Rp)
(0,00)
(Rp.)
(0,00)
(Rp)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
K. Alcoholic
Bottle
beverages
174 Beer
700 cc
175 Wine
Bottle
700 cc
176 Other alcoholic
beverages
177 Sub-total (K)
Ser Detail
ial
num
ber
178
179
180
181
182
183
184
185
186
187
188
L. Tobacco, betel
White tobacco
“Commodore”
cigarettes
White tobacco
“Kansas” cigarettes
Other white
tobacco cigarettes
Clove cigarettes
(“Gudang Garam”)
“Bentoel” clove
cigarettes
Other clove
cigarettes
Cigar
Tobacco
Betel/areca nut
Others
Sub-total (L)
20 pieces
20 pieces
20 pieces
Pieces
Pieces
Pieces
Pieces
Ounce
25
26
II.2. EXPENDITURES FOR NON-FOOD GOODS
DURING THE PAST 3MONTHS /PREVIOUS MONTH
Serial
Detail
Value in Rupiah
number
3 months ago
Previous month
(1)
(2)
(3)
(4)
189
A. Housing, Fuel, Lighting and Water
The house you are occupying is:
Own property/free of rent -1
Rented
-3
Leased
-2
Other
-4
190
If the house is own property/free of rent,
Estimate monthly rent value: Rp. ………………..
191
If the house is lease
a. Lease agreement
: …………… year
b. Value of lease
: Rp……………..
c. Average monthly lease value : Rp. ……………..
192
If this house rented, value of monthly rent: Rp. ……………..
193
If the status is ‘ other’ (installment, official house, etc)
Average monthly rent value: Rp. ………………………
194
Maintenance expenses (painting, replacement of roof tiles, broken
glass, hinge, etc)
195
Electricity:
Quantity:
3 months ago ……………….kwh/watt*)
A month ago: ……………….kwh/watt
196
Value
197
Gas:
Quantity:
3 months ago ……………….m3
A month ago: ……………….m3
Value
198
199
LPG (Liquid Propane Gas)
Quantity:
3 months ago ……………….kg
A month ago: ……………….kg
200
Value
201
Kerosene:
Quantity:
3 months ago ……………….liter
A month ago: ……………….liter
Value
202
*) cross out either one
27
28
Serial
number
(1)
203
II.2. EXPENDITURES FOR NON-FOOD GROUP
DURING THE PAST 3MONTHS /PREVIOUS MONTH
Detail
Value in Rupiah
3 months ago
Previous month
(2)
(3)
(4)
Generator:
a. Gasoline:
Quantity:
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
Value
b. Lubricant oil:
Quantity:
3 months ago ……………….liter
A month ago: ……………….liter
3 months ago ……………….liter
A month ago: ……………….liter
Value
c. Maintenance and repair:
Charcoal:
Quantity:
3 months ago ……………….kg
A month ago: ……………….kg
Value
Firewood
Water
Other (battery, dry-cell battery, matches, etc)
Sub-total (A)
B. Goods, services
Toilet soap, tooth paste, and shampoo
Cosmetics (pomade, perfume, talc/powder, hairspray, etc)
Treatments: skin, face, hair, nails, etc
Health
1. Doctor’s fees
2. Medical treatment costs
3. Midwife fees
4. Contraceptive costs
5. Traditional healer fees
6. Medication, with doctor’s prescription expenses
7. Medication, OTC
8. Other
29
30
Serial
number
(1)
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
II.2. EXPENDITURES FOR NON-FOOD GROUP
DURING THE PAST 3MONTHS/PREVIOUS MONTH
Detail
Value in Rupiah
3 months ago
Previous month
(2)
(3)
(4)
School/course expenses:
1. School fee, routine fees
2. Other school contributions
3. Enrollment fee
4. Books
5. Stationery
6. Course(s) fees
Magazine, newspaper, books and stationary (not including books for
courses, including rent for magazine/reading material)
Postage and telegram (telephone, stamps, etc)
Transportation cost
Gasoline:
Quantity: 3 months ago: ……………….. liter
A month ago: ……………….. liter
Value:
Lubricant oil:
Quantity: 3 months ago: ……………….. liter
A month ago: ……………….. liter
Value:
Repair and maintenance of vehicle
Other transportation (bus, train, ship/air plane/, ‘pedicab’. Etc)
Cinema, theatre, sport and other recreations
(excluding transport and equipment for recreation)
Domestic help (salary or wage only)
Others (tooth brush, camphor, etc)
Sub-total (B)
C. Clothing, Footwear, and Head gear
Men’s ready to wear clothes ( Suit, shirt, jacket, sarong, trousers, Tshirt, under wear, etc)
Women’s ready to wear clothes (gown, batik, blouse, house dress,
sweater, skirt, longdress, shawl, girdle, under wear)
Children’s ready to wear (clothes, pants, sweater, socks, etc)
31
32
Serial
number
(1)
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
II.2. EXPENDITURES FOR NON-FOOD GROUP
DURING THE PAST 3MONTHS/PREVIOUS MONTH
Detail
Value in Rupiah
3 months ago
Previous month
(2)
(3)
(4)
Men’s fabrics (‘famatex’, wool, ‘Tetoron’, etc)
Women’s fabrics (“Yersi”, Paris, “Popline”, ‘Tetoron”, etc)
Children’s fabrics
Sewing and repair of clothes costs
Men’s Footwear (shoes, sandal, socks, etc)
Women’s Footwear
Children’s Footwear
Head gear for men, women, and children (hat, rimless cap/peci, etc)
Thread and other sewing needs
Laundry soap (bar) (‘sap tangan’, ‘B29’, etc)
Detergent powder (‘Rinso’, ‘Dino’, etc), Cream (‘B 29’, ‘Ekonomi’,
etc)
Others (towel, belt, shoe polish, laundry, etc)
Sub total (C )
D. Durable goods
Furniture (table, chairs, bed, sideboard, cupboard, sewing machine,
refrigerator, fan, etc)
Household equipment (mattress, pillow, table cloth, bed sheet, ,
blanket, curtain, carpet, etc)
Household utensils (Iron, broom, scissors, electric equipments, knife, ,
saw, etc)
Kitchen and eating utensils (plate rack, stove, frying pan, pan, pail,
wok, spoon, thermos bottle, plate, glass, and other breakable utensils
Repair of household utensils and equipment
Clock, Wrist watch, camera, glasses, and its repair
Umbrella, bag, luggage, and its repair
Gold, diamond, pearls, etc (expensive jewelry)
Children toys, cheap jewelry
Entertainment equipment’s (TV, radio, cassette player, guitar, piano,
etc) and repair
33
34
Serial
number
(1)
269
270
271
272
II.2. EXPENDITURES FOR NON-FOOD GROUP
DURING THE PAST 3MONTHS/PREVIOUS MONTH
Detail
Value in Rupiah
3 months ago
Previous month
(2)
(3)
(4)
Sport equipment (Chess, checkers, racket, ball, net, etc) and repairs
Vehicle (bicycle, motorcycle, car) and repairs
Other durable goods (wall decoration, aquarium, etc) and repairs
Sub total (D)
E. Utility taxes and insurance
273
274
275
276
277
278
‘Ipeda’, ‘Ireda’
Radio/TV taxes
Motor and non-motor vehicle taxes
Other levies (contribution, donation, etc)
Life, fire, accident insurances.
Sub total (E)
F. Festivities and ceremonial Needs
279
280
281
282
283
284
Wedding
Circumcision, birthday
Religious festivals (Lebaran, Christmas/New Year, Galungan)
Traditional ceremony/others (‘selametan’, offering, etc)
Burial
Sub total (F)
35
36
II.3. SUMMARY OF HOUSEHOLD EXPENDITURES
Serial
number
(1)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Type of expenditures
(2)
Cereals (II.1 A)
Tuber (II.1 B)
Fish (II.1 C)
Meat (II.1 D)
Egg and Milk (II.1 E)
Vegetables (II.1 F)
Pulses (II.1 G)
Fruits (II.1 H)
Other consumption (II.1 I)
Food and Beverages (II.1 J)
Alcoholic beverages (II.1 K)
Tobacco and betel (II.1 L)
Sub total (1 to 12)
Sub total (13) x 30
7
Expenses for housing, fuel, lighting and water (II.2 A)
Expenses for goods and services (II.2B)
Expenses for clothing, footwear, and head gear (II. 2C)
Expenses for durable goods (II.2D)
Utility tax and insurance (II.2E)
Expenses for festivities and ceremonies (II.2F)
Total expenses (14 to 20)
During one
week
(Rp)
(3)
During 3
months
(Rp)
(4)
During a
month
(Rp)
(5)
37
38
III.1. INCOME/REVENUE AND OTHER EXPENDITURE DURING THE PREVIOUS MONTH
A. wage/salary received during the previous month
Name of household members Main
Serial number
Wage/salary (Rp)
worked as a workers
activity/job
of household
Additional
Over time Honorarium
Total
members likes
job
col. (1) block
I.1
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Total
B. Gross income from ………………????
C. Other Income/Revenue during previous month
Income/Revenue
Rp
(1)
(2)
1. Interest
2. Rent/Lease
3. Pension
4. Donation/gift
5. Debit from savings account
6. Sale of bond/immovable goods
7. From pawned goods
8.
Other Expenditures during previous month
Type of expenditure
Rp
(1)
(2)
1. Money transfers made/donation
2. Savings
3. Purchase of bond/immovable goods
4. Insurance
5. Loans made/Loans paid back
6. Other
39