The English Translation of the Japanese Questionnaire Form (PDF:414KB)

(1) The English Reference12. Enumetation Documents ⺞ᩏ␿䈱ኻ⸶䋨⧷⺆䋩 ╙䋱㕙 translation of This is an English translation of the Japanese questionnaire form. Please fill out the form the Japanese referring to“How to fill out a questionnaire form”. You need to use a black pencil or a questionnaire mechanical pencil for filling out the form. If you fail to fill out correctly, erase it using a gum eraser. A completed form will be mechanically handled, so please do not soil the form. form 1. Name and sex 1 (Name) 䊶 Write the names of all persons who make up your household. Male Female Head or Parent(s) of 2. Relationship to the householder Spouse of Spouse(s) of Parent(s) of representative Child(ren) householder's 䊶 householder child(ren) householder Mark "Grandparent(s)" for the grandparent(s) of the householder's wife or husband. of household spouse 䊶 Mark "brother/sister(s)" for the brother(s)/sister(s) of the householder's wife or husband. 䊶 Mark "grandchild(ren)" for the grandchild(ren)'s wife(wives) or husband(s). Grandchild Grandparent Brother(s)/ Other Live-in Others 䊶 Mark "brother(s)/sister(s)" for the wife(wives) or husband(s) of your (ren) (s) sister(s) relative(s) employee(s) brother(s) and sister(s). 3. Year and month of birth Meiji Taisho Showa Heisei Christian Year 䊶 After marking Christian Year, enter the year (in 4 digit) and the month. Year Month Never got married 4. Marital status Widowed Divorced 䋨Including small children䋩 Married 䊶 Indicate the marital status regardless of whether or not it is officially (Name of country) 5. Nationality 㪡㪸㫇㪸㫅㪦㫋㪿㪼㫉㫊䊶 If other than Japanese, write the name of the country. 6. Period of living at the present domicile 䊶 If you have been living at the present domicile since your birth, mark "Since birth" only. Since birth Since Less 1 year than 5 years less than 1 to 10 years less than 5 to 20 years less than 10 to 20 years or more For every member of your household your of member every For 7. Where did you live five years ago (as of October 1, 2005)? Enter the location at which you lived 5 years ago. 䊶 A person born after October 1, 2005, should mark the place Another place within at which he/she lived after his/her birth. Same as the same Another Outside of present municipality municipality Japan 䊶 If you have marked "Another place within the same municipality" or "Another municipality", write the name of the prefecture and (Specify the location.) municipality. (If you live in Tokyo Metropolitan area or Prefecture ordinance-designated cities, write the name of the ward as well.) 㪚㫀㫋㫐䊶 "Ordinance-designated cities" refers to the following cities: local county Sapporo, Sendai, Saitama, Chiba, Yokohama, Kawasaki, Sagamihara, Niigata, Shizuoka, Hamamatsu, Nagoya, Kyoto, 㪮㪸㫉㪻㪆㫋㫆㫎㫅 Osaka, Sakai, Kobe, Okayama, Hiroshima, Kitakyushu, Fukuoka 㪆㫍㫀㫃㫃㪸㪾㪼 About your household (When using two or more questionnaire forms, fill out (1) to (4) on the first.) (1) Number of household members (3) Type of building Male including Apartment Total Female Detached Tenement terrace house house house house or flat Others persons persons persons The floor on (2) Kind of housing Total number of floors which you live Housing for Rented house Rented house Housing for company bachelors owned by employee and civil floors floor Household owned by the Urban Rented house servant apartment and prefectural and Renaissance Agency owned by Rented dormitory Owned municipal and housing private room Others (4) Total area of floor space 20 to less 30 to less 40 to less 50 to less 60 to less 70 to less house corporations corporations company Less than than than than than than than 2 2 2 2 2 2 • Total area covers living room 20m2 30m 40m 50m 60m 70m 80m entrance, kitchen, toilet, bathroom and corridor. Proceed to (3) • (4) Proceed to the back side 80 to less 90 to less 100 to less 120 to less 150 to less 200 to less • Areas used for business than than than than than than 250m2 The following sections should be left blank. use or occupied by other 90m2 100m2 120m2 150m2 200m2 250m2 or more households should not be ਎Ꮺ ৻⥸਎Ꮺ ቇᩞ䈱ኰ䊶 ∛㒮䊶 ⠧ੱ䊖䊷䊛 included. 䈱 ৻ੱ਎Ꮺ ળ␠╬䈱 ነኋ⥢䈱 ≮㙃ᚲ䈱 ╬䈱␠ળᣉ 䈠䈱ઁ You may be contacted for additional ⁛りኰ䈱౉ዬ⠪䉕฽䉃 ቇ↢䊶↢ᓤ ౉㒮⠪ ⸳䈱౉ᚲ⠪ Phone No. ⒳㘃 information if necessary. Ꮢ඙↸᧛䉮䊷䊄⺞ᩏ඙⇟ภ ਎Ꮺ⇟ภ 䈖䈱਎Ꮺ䈱⺞ᩏ␿ ⠡⸶ Continued overleaf ᨎ䈱 (Page 2). 䈉䈤 ᨎ⋡ 1 - 744 - This is the back side. Please start with the front side. 㪈䇭䇭䇭䇭䇭䇭⺞ᩏ␿䈱ኻ⸶䋨⧷⺆䋩䇭╙䋲㕙 8. Schooling In school Graduated Preschool 䇭 •㩷Mark your schooling status by following the arrow. ޓ 䇭 •㩷Select the school you are in if you are attending school. If you are no longer in school, select the school you graduated from. Primary/ Nursery High school (If you dropped out from school, select the last school you junior high Kindergarten Daycare center school graduated from.) University Junior/technical Graduate Infant college school Others 9. Did you do any work during the week from Engaged in Did housework, etc. Attended school and work worked 24th to 30th of September? Yes 䇭 • "Work" refers to any work you did for profit such as salary. Proceed to 10 to 14. Every household member 䇭• Assisting family business (farming, stores, etc.), 䇭 Others working at piece rates and doing part-time job are also Attended Absent from Looked for Did Infant, included here. school work work Housework aged, etc. 䇭 • "Attended school" includes attending technical schools No such as officially registered Japanese language schools. End of End of questionnaire Proceed to 10 to 14. questionnaire Write 10 and 11 only. 10. Place of work or schooling Home Within the same Another including live-in municipality municipality 䇭• If you both work and attend school, mark the place of work. employees 䇭• If you have marked "Within the same municipality" or "Another 䋨䋩 municipality", enter the name of the prefecture and municipality. Proceed to 12. Write place of work or schooling. ޓ ޓ (If the place of work or schooling is located in Tokyo Metropolitan area or ordinance-designated cities, write the name of the ward Prefecture as well.) ޓ• "Ordinance-designated cities" refers to the following cities: City Sapporo, Sendai, Saitama, Chiba, Yokohama, Kawasaki, local county Sagamihara, Niigata, Shizuoka, Hamamatsu, Nagoya, Kyoto, Osaka, Sakai, Kobe, Okayama, Hiroshima, Kitakyushu, Fukuoka 㩷㪮㪸㫉㪻㪆㫋㫆㫎㫅㩷㪆㫍㫀㫃㫃㪸㪾㪼 11. Means of transportation to your place of work or Bus owned/ Persons who work or attend school work Persons who rented by schooling On foot Train Bus 䇭䇭 company/school 䇭• When using two or more means of transportation, select them all. Taxi/ Private car limousine Motorcycle Bicycle Others 12. Employed or self-employed Employed Regular Temporary Part-time Board member of 䇭 • Contracted employees and non-regular employees are included in employee employee employee and company, etc. the category of "Part-time employees and others". others 䇭 • "Self-employed" refers to persons who run businesses on their own Self-employed or who work on free-lance basis. Employing Not employing Family Piece rate work others others employees 13. Name of workplace and kind of business Refer to Page 8 of "How to fill out a questionnaire form" and write in detail. 䇭• Write the name of workplace at which you worked Name of (head office, branch office, sales office, factory, store, etc.) workplace Persons who work Persons who 䇭 • Describe in detail the kind of business occuring at the workplace. 䇭 Kind of • If you are a temporary worker, write about the workplace to business which you are sent off. 䋱䋴䇭Description of work 䇭 • Describe in detail the duties you are assigned to perform. 2 Thank you for your cooperation. - 745 -.

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