Glue Area Fieldworker ID No

STATISTICS ACT NO. 6 OF 1999 (CONFIDENTIALITY) 17(1) Despite any other law, no return or other information collected by Statistics South Africa 18(1e) Any officer of Statistics South Africa who willfully discloses any data or for the purposes of official or other statistics that relates to an individual or a household 18(1g) information obtained in the course of such employment to a person not authorised may be disclosed to any person. to receive that information is guilty of an offence and liable on conviction to a fine 17(3b) Any person who is involved in the collection of, or who may use, that information or data, not exceeding R10 000, or to imprisonment for a period not exceeding 6 months or must first take an oath of confidentiality. to both. ENUMERATION AREA NUMBER

Province ...... Local municipality......

Main place ...... Sub-place ...... Physical identification of the dwelling unit ......

...... Postal code Landline/Cell phone of enumerated household ......

PARTICULARS OF THE HOUSEHOLD Dwelling unit number Total number of persons Males Females Total in the household Household number

Total number of households at this dwelling Questionnaire of completed for this household Map reference number Listing record number If more than one questionnaire is used in the household, write the barcode of the 1st questionnaire below

METHOD OF QUESTIONNAIRE COMPLETION - Mark the appropriate circle with an X A fieldworker through an interview A household member through self-completion FIELD STAFF Glue area Fieldworker ID No. Supervisor ID No.

Signature ...... Signature ......

RESPONSE DETAILS RESULT RESPONSE Interview Next Visit (Planned) CODE DETAILS Visit No. Date (actual) Start Time End Time Result Code Date Time 1 Completed 2 Partly completed 1 3 Non-contact 2 4 Refusal 3 5 Unoccupied dwelling 6 Vacant dwelling 4 7 New dwelling under construction 8 Demolished dwelling Comments and full details of all non-response / unusual circumstances 9 Status change

...... FINAL RESULT CODE

......

SHOULD YOU ENCOUNTER ANY DIFFICULTIES IN THE COMPLETION OF THE QUESTIONNAIRE, PLEASE CONTACT:

...... ON ......

OR PHONE THE CENSUS HOTLINE, TOLL FREE, ON ......

Census 2011 - A© Statistics South Africa, July 2010 FLAP: PARTICULARS OF ALL INDIVIDUALS

Please write the name and surname of the household head and first names of every person who was present in this household on the night between 9 - 10 October. One name on each row. Start with head or acting head of household. The head or acting head is the person who is the main decision-maker in the household. If people are equally decision-makers, take the oldest person. For babies with no name, write BABY. Have you included babies, small children, old people and visitors who were present in this household on the night between 9 - 10 October? F-00 F-01 PERSON NAME F-02 AGE IN F-03 SEX PERSON COMPLETED 1 = Male NUMBER YEARS 2 = Female

Example Example Example

JOH N M A L X 1 Male 0 3 1 ULEKE 2 Female Mark the appropriate circle with an X.

1 Male 1 2 Female

1 Male 2 2 Female

1 Male 3 2 Female

1 Male 4 2 Female

1 Male 5 2 Female

1 Male 6 2 Female

1 Male 7 2 Female

1 Male 8 2 Female

1 Male 9 2 Female

1 Male 0 2 Female

Census 2011 - A© Statistics South Africa, July 2010 PROCEDURES OF ENUMERATION

Who should be the respondent? How to complete the questionnaire - The head/acting head of the household. - Read every question carefully - In the absence of head/acting head, any responsible adult member left in - Make sure that all the codes are written inside the boxes. charge of the household. For example: Note: 3 3 A household is a group of persons who live together, and provide themselves Correct Incorrect jointly with food or other essentials for living, or a single person who lives alone. - For numeric values such as age, the enumerator/respondent should - Domestic workers are counted as a separate household even if they live in the write the correct answer in the box as a number (e.g. “007” ). same household as the employer. Who should be counted in this questionnaire? 0 0 7 - All persons present in the household on the reference night (midnight 9-10 - For open-ended questions, the enumerator/respondent should write October 2011) legibly in CAPITAL LETTERS in the boxes provided. - Include babies born before the reference night as well as visitors. For example Cape Town should be written as: - Members who died after the reference night must be counted as alive. - Members of the household who were absent overnight, for example working, CAPETOWN travelling or at an entertainment venue, religious gathering, if they returned to the household the next day. - Individuals in converted workers hostels, residential hotels and old age homes What to use when completing this questionnaire? (depending on arrangement). Use only a pencil. If you make a mistake, use a soft rubber to erase the mistake and write the correct answer.

Census 2011 Census 2011 Census 2011 SECTION A: DEMOGRAPHICS - ASK OF EVERYONE LISTED ON THE FLAP

P-01 DATE OF P-02 RELATIONSHIP P-03 MARITAL P-04 SPOUSE OR P-05 POPULATION P-06 LANGUAGE BIRTH STATUS PARTNER GROUP What is (name’s) What is (name’s) relationship to the head What is (name’s) Who in this house- How would (name) Which two languages date of birth? or acting head of the household? PRESENT hold is (name’s) describe him/herself does (name) speak most The head or acting head is the person listed marital status? spouse or partner? in terms of often in this household? in row 1 of the first questionnaire, if more 1 =Married population group? 01 = Afrikaans than one questionnaire has been completed 2 =Living Write the person 1 = Black African 02 = English for this household. together like number of the spouse 2 = Coloured 03 = IsiNdebele 01 = Head/Acting Head married or partner in the 3 = Indian or Asian 04 = IsiXhosa 02 = Husband/Wife/Partner partners 05 = IsiZulu appropriate box. 4 = White 06 = Sepedi 03 = Son/Daughter 3 =Never married If the spouse or 5 = Other 04 = Adopted Son/Daughter 07 = Sesotho 4 =Widower / partner does not 05 = Stepchild Write the appropriate 08 = Setswana widow reside in the house- code in the box. 09 = SiSwati Example 06 = Brother/Sister 5 =Separated 07 = Parent (Mother/Father) hold, write 98. 10 = Tshivenda 6 =Divorced 11 = Xitsonga 1 9 08 = Parent-in-law Note: Refer to person 12 = Other 09 = Grand/Great Grandchild on flap e.g. 02 0 4 10 = Son/Daughter-in-law Write the Write the appropriate code 11 = Brother/Sister-in-law appropriate code in the box. 1 7 9 9 12 = Grandmother/Father in the box. If no other language, write 13 = Other relative 00 in the second box. 14 = Non-related person If 3-6, Go Write the appropriate code in the box. to P-05

D D First M M Second Y Y Y Y

D D First

M M Glue area Second Y Y Y Y

D D First M M Second Y Y Y Y

Census 2011 - A© Statistics South Africa, July 2010 Glue area SECTION B:MIGRATION - ASK OFEVERYONE LISTEDONTHEFLAP code inthebox. Write theappropriate 1=Donotknow = 11 Outside South = 10 Limpopo = 09 Mpumalanga = 08 Gauteng = 07 NorthWest = 06 Kwa-Zulu Natal = 05 FreeState = 04 NorthernCape = 03 EasternCape = 02 Western Cape = 01 (name) In whichprovincewas P-07 OF BIRTH If 01-09or11, Africa PROVINCE Go toP-09 born? Use CAPITAL In whichcountry P-08 LETTERS only was OF BIRTH (name) COUNTRY born? P-08a last move. indicate theyearof Africa, please once intoSouth If movedmorethan South Africa? (name) In whichyeardid MOVED TOSOUTH AFRICA Y Y Y Y Y Y Y Y Y Y 198 Example YEAR moveto Y Y Y Y Y Y Y Y Y Y 9 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Mark the 2 =No 1 = Yes Is P-09 with anX. appropriate circle African citizen? CITIZENSHIP AFRICAN (name) SOUTH 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No aSouth 2 =No 1 = Yes six months? so forthelast and hasdone nights aweek for atleastfour this household usually livein Does P-10 Mark the with anX. appropriate circle RESIDENCE Go toP-11 USUAL (name If 1, 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No ) code inthebox. Write theappropriate 1=Donotknow = 11 Outside South = 10 Limpopo = 09 Mpumalanga = 08 Gauteng = 07 NorthWest = 06 Kwa-Zulu Natal = 05 FreeState = 04 NorthernCape = 03 EasternCape = 02 Western Cape = 01 live? does In whichprovince RESIDENCE USUAL P-10a Africa Go toP-11 (name PROVINCE OF If 10, ) usually Census 2011 - A In which USUAL RESIDENCE OF MAGISTERIAL DISTRICT P-10b only Use CAPITAL LETTERS live? does magisterial district © (name) MUNICIPALITY/ Statistics South Africa, July 2010 municip usually ality or ality Glue area BU ES Example G live before or CITY/TOWN OF CITY/TOWN JOHAN N R PREVIOUS RESIDENCE P-11d In which city/town did (name) what was the nearest city/town? LETTERS Use CAPITAL only live before OBUR Example ME TR MUNICIPALITY/ (name) J O G MAGISTERIAL DIS- TRICT OF PREVIOUS moving to this place? LETTERS Use CAPITAL only P-11c RESIDENCE Inwhich municipality or magisterial district did live (name) If 10, Go to P-12 PROVINCE OF PREVIOUS P-11b RESIDENCE In which province did place? before moving to this 01 = Cape Western 02 = Eastern Cape 03 =Cape Northern 04 = Free State 05 = Natal Kwa-Zulu 06 = North West 07 = Gauteng 08 = Mpumalanga 09 = Limpopo 10 =Africa South Outside 11 = Do not know Write the appropriate code in the box. Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y (name) 4 Y Y Y Y Y Y Y Y Y Y M M M M M M M M M M MONTH AND MONTH 0 2002 Example Y Y Y Y Y Y Y Y Y Y M M M M M M M M M M move to this place? year in the appropriate boxes. YEAR MOVED When did Write the month and P-11a been ) If 1 or 3, SINCE 2001 Go to P-12 (name October 2001 but never moved October 2001 and moved code in the box. Write the appropriate Has P-11 P-11 living in this place since October 2001? 1=Yes 2=No 3 = Born after 4 = Born after usually Statistics South Africa, July 2010 South Statistics ESIDENCE © (name) CITY/TOWN OF CITY/TOWN P-10c USUAL R In which city/town does live or what is the nearest city/town? Use CAPITAL LETTERS only Census 2011 - A - Census 2011 SECTION B: MIGRATION (Continued) B: MIGRATION SECTION Glue area ASK OFEVERYONE LISTEDONTHEFLAP SECTION C:GENERAL HEALTH AND FUNCTIONING- Does P-12 Write theappropriatecodeinbox. F = With self-caresuchaswashingallover,F =With E =Rememberingorconcentrating D =Walkingorclimbingstairs C =Communicatinginhis/herlanguage(i.e. B =Hearingevenwhenusingahearingaid A =Seeingevenwhenusingeyeglasses HEALTH AND FUNCTIONING dressing orfeeding by others) understanding othersorbeingunderstood Cannotyetbedetermined = 6 Donotknow = 5 Cannotdoatall = 4 A lotofdifficulty = 3 Somedifficulty = 2 Nodifficulty = 1 (name) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) Communicating (C) Hearing (B) Seeing (A) have difficultyinthefollowing? Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Self-care (F) Walking /Climbing(D) Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Concentrating (E) Remembering / Write theappropriatecodeinbox. E =Chronicmedication = D A wheelchair C =Walking stickorframe B =Hearingaid A =Eyeglasses Does MEDICATION P-13 3 =Donotknow 2 =No 1 = Yes Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Walking stick/frame(C) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) Hearing aid(B) Glasses (A) ASSISTIVE DEVICES AND ASSISTIVE (name) use anyofthefollowing? Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) Wheelchair (D) medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic medication (E) Chronic Mark theappropriate ALIVE P-14 circle withanX. Donotknow 3 = No 2 = Yes 1 = still alive? biological mother Is THE FLAP INCOME - ASK OFEVERYONE LISTEDON SECTION D:PARENTAL SURVIVAL AND (name’s) MOTHER Go to P-15 Go to 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow If 2-3, own flap e.g.02 person numberon Note: write 98. listed ontheflap), household (not reside inthe mother doesnot If theperson’s mother? (name’s) household is Who inthis PERSON NUMBER P-14a Refer to MOTHER biological Census 2011 - A © Mark the with anX. appropriate circle Donotknow 3 = No 2 = Yes 1 = still alive? biological father Is ALIVE P-15 Statistics South Africa, July 2010 (name’s) (name’s) Go to P-16 Go to FATHER 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow If 2-3, own Glue area is 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Public 1 Public 1 Public 1 Public 1 Public 1 Public 1 Public 1 Public 1 Public 1 Public 2 Private 2 Private 2 Private 2 Private 2 Private 2 Private 2 Private 2 Private 2 Private 2 Private PUBLIC OR (name) (Government) (Independent) P-19 PRIVATE Is the institution that attending public or private? 1 = Public 2 = Private 3 = not know Do circle with an X. Mark the appropriate attend? EDUCATIONAL crèche, pre-primary, ECD centre) crèche, pre-primary, school) learners who attend a formal Learning Centre (ABET Centre) SANLI) Technology) (University/University of College (FET) schooling 1 = (including day care, Pre-school 2 = School (including Grade R 3 =Training Adult Basic Education and 4 = (e.g. Kha Ri Gude, Literacy classes 5 = Higher Educational Institution 6 =Training Further Education and 7 = College Other 8 = Home based education/home P-18 INSTITUTION Which of the following does educational institutions (name) 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No (name) SCHOOL If 2-3, Go to P-20 to If 2-3, Go SECTION E: EDUCATION - ASK OF ALL PERSONS ALL ASK OF - E: EDUCATION SECTION OLDER LISTED ON THE FLAP AND YEARS AGED 5 P-17 ATTENDANCE Does presently attend an educational institution? Yes 1 = 2 = No 3 = Do not know circle with an X. Attendance includes and full- all part-time time studies, whether in person or as a learner. distance Mark the appropriate ) name ( all sources of income ances, rentals, INCOME CATEGORY investments, sales or products, services, etc. sales or products, investments, Gross income should include remitt UIF, e.g. Social grants, What is the income category that best describes What is the income category annual income of the gross monthly or Monthly01 = No income02 = R1 - R40003 = R401 - R80004 = R801 – R1 60005 = R1 601 – R3 20006 = R3 201 – R6 400 No 07 = R6 401 – R12 800income 08 = R12 801 – R25 600 R1 - R4 800 R4 801 – R9 600 R9 601 – R19 200 R19 201 – R38 400 Annual 09 = R25 601 – R51 200 R38 401 – R76 800 10 = R51 201 – R102 400 600 R76 801 – R153 R153 601 – R307 200 = R102 401 – R204 80011 R307 201 – R614 400 12 = R204 801 or more – R1 228 800 R614 401 R1 228 801 – R2 457 600 R2 457 601 or more P-16 including all sources of before deductions and income? Statistics South Africa, July 2010 South Statistics © (name’s) FATHER Refer to person P-15a PERSON NUMBER Who in this household is biological father? father If the person’s does not reside in the household (not listed on the flap), write 98. Note: number on flap e.g. 02 Census 2011 - A - Census 2011 SECTION D: PARENTAL SURVIVAL AND INCOME SURVIVAL D: PARENTAL SECTION (Continued) Glue area SECTION E:EDUCATION (Continued) What isthehighestlevelofeducationthat P-20 duration full-time(orequivalent). have beenatleastsixmonthsstudy READ OUT: Diplomaorcertificateshould 4=NTCII/N2/NIC/(V)Level3 14 = NTCI/N1/NIC/(V)Level2 13 = Grade12/Std 10/Form5 12 = Grade11/Std 9/Form4 11 = Grade10/Std 8/Form3 10 = Grade9/Std 7/Form2/ 09 = Grade8/Std 6/Form1 08 = Grade7/Std 07 = Grade6/Std 4 06 = Grade5/Std 05 = Grade4/Std 2 04 = Grade3/Std 1/ABET 1 03 = Grade2/SubB 02 = Grade1/Sub A 01 = Grade0 00 = Noschooling 98 = ABET 4 (Kha RiGude,SANLI) LEVEL OFEDUCATION If 98or00-07,GotoP-22 If 08-12, GotoP-23 08-12, If 5 / ABET 3 3 / ABET 2 9=Other 29 = Higherdegree(Masters/PhD) 28 = Honoursdegree 27 = BachelorsdegreeandPostgraduate 26 = Bachelorsdegree 25 = PostHigherDiploma(Masters,Doctoral 24 = Higher Diploma 23 = DiplomawithGrade12/Std 10 22 = CertificatewithGrade12/Std 10 21 = DiplomawithlessthanGrade12/Std 10 20 = CertificatewithlessthanGrade12/ 19 = N6/NTC 6 18 = N5/NTC 5 17 = N4/NTC 4 16 = NTCIII/N3/NIC/(V)Level4 15 = code inthebox. Write theappropriate diploma Diploma) Std 10 (name) If 13-29,GotoP-21 has completed? In whichfieldis P-21 2=SocialSciencesorStudies 22 = Public Administration orSocialServices 21 = Psychology 20 = PhysicalEducationorLeisure 19 = Philosophy, Religionor Theology 18 = Sciences Military 17 = Sciences Mathematical 16 = LifeSciencesorPhysical 15 = Librariesor Museums 14 = Law 13 = Languages,LinguisticsorLiterature 12 = Industrial Arts, 11 = Economics Home 10 = HealthCareorSciences 09 = Engineeringor Technology 08 = Education, Training orDevelopment 07 = Sciences Computer 06 = Communication 05 = Business,CommerceorManagement 04 = Arts, Visual orPerforming 03 = ArchitectureorEnvironmental Design 02 = AgricultureorRenewableNatural 01 = FIELDOFEDUCATION Sciences Resources (name’s) Traders or Technology Any response, Goresponse, toAny P-23 highest post-schoolqualification? 7=Other 37 = EducationandDevelopment 36 = Mechatronics 35 = Safetyinsociety 34 = Tourism 33 = Hospitality 32 = PrimaryAgriculture 31 = Engineering 30 = CivilEngineeringandBuilding 29 = Infrastructure Electrical 28 = Office Administration 27 = Finance,Economicsand 26 = Technology Information and 25 = Marketing 24 = Management 23 = TRAINING FIELDSOFEDUCATION FURTHER EDUCATION AND code inthebox. Write theappropriate Construction Construction Accounting Computer Science Census 2011 - A © Statistics South Africa, July 2010 Glue area 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No help without being … (name) (name) an X. Did of business in any kind paid even run by her/his household, hour? if it was for only one Yes 1 = 2 = No 3 = Do not know Mark the appropriate circle with In the SEVEN DAYS before 10 In the SEVEN DAYS October P-23c 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No run or do any kind … (name) (name) with an X. Did of business, big or small, for of business, big or small, one or herself/himself or with even if it was more partners, for only one hour? Yes 1 = 2 = No 3 = Do not know Mark the appropriate circle In the SEVEN DAYS before 10 before In the SEVEN DAYS October P-23b If 1 to any of P-23a, P-23b or P-23c, Go to P-29a If 1 to any of P-23a, P-23b or P-23c, Go to work for a wage, 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No … EMPLOYMENT STATUS EMPLOYMENT (name) (name) with an X. Mark the appropriate circle In the SEVEN DAYS before 10 before In the SEVEN DAYS October P-23a Did commission or any salary, (including in kind payment domestic work), even if paid it was for only one hour? Yes 1 = 2 = No 3 = Do not know SECTION F: EMPLOYMENT - ASK OF ALL PERSONS AGED 15 YEARS AGED 15 PERSONS ALL ASK OF - F: EMPLOYMENT SECTION ON THE FLAP AND OLDER LISTED P-23 Writing a letter (D) Writing Writing a letter (D) Writing a letter (D) Writing a letter (D) Writing a letter (D) Writing a letter (D) Writing Writing a letter (D) Writing Writing a letter (D) Writing a letter (D) Writing a letter (D) Writing Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Reading road signs (F) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) Calculating (E) have difficulty in doing any of the following? have difficulty in doing ) Statistics South Africa, July 2010 South Statistics © name ( books etc) in any language he/she should receive when buying something Writing his/her name (A) Writing Writing his/her name (A) Writing Writing his/her name (A) Writing his/her name (A) Writing Writing his/her name (A) Writing Writing his/her name (A) Writing his/her name (A) Writing Writing his/her name (A) his/her name Writing Writing his/her name (A) his/her name Writing (A) his/her name Writing Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling in a form (C) Reading (B) Filling a form (C) 1 = No difficulty 2 = Some difficulty lot of difficulty A 3 = 4 = Unable to do 5 = Do not know Write the code in the appropriate box. LITERACY A =B name his/her Writing = magazines, religious Reading (e.g. newspapers, C =D forms) Filling in a form (e.g. social grants =E a letter in any language Writing = Calculating/working out how much change F = Reading road signs Does P-22 Census 2011 - A - Census 2011 SECTION E: EDUCATION SECTION (Continued) Glue area SECTION F:EMPLOYMENT(Continued) Mark theappropriatecircle with anX. 3 =Donotknow 2 =No 1 = Yes to? would definitelyreturn business thathe/she have apaid jobor 10 October, didhe/she the SEVENDAYS before household businessin paywithout in a profit ordidnothelp not doanyworkforpay, Even though ABSENCE FROMWORK P-24 TEMPORARY Go toP-29a 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow If 1, (name) did Mark the with anX. appropriate circle 3 =Donotknow 2 =No 1 = Yes kind ofbusiness? trying tostart any kind ofjobor looking forany was before 10October In thefourweeks FOR WORK P-25 Go toP-28 (name) LOOKING 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow If 1, 3 =Donotknow 2 =No 1 = Yes before 10October? SEVEN DAYS liked toworkinthe Would WORK P-26 Mark theappropriate circle withanX. Go toP-32 LIKED TO If 2or3, 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow (name) have starting abusinessinthelastfourweeksbefore10October? What wasthemainreasonfornottryingtofindworkor P-27 7=Other = 17 Didnotwanttowork = 16 Too old/youngtowork 15 = Retired 14 = Scholarorstudent = 13 Notransportavailable = 12 Losthopeoffindinganykindwork = 11 Unabletofindworkrequiringhis/herskills = 10 Lackofmoneytopay fortransporttolookwork 09 = Nojobsavailableinthearea = 08 Undergoingtrainingtohelp find work = 07 Housewife/homemaker(familyconsiderations/childcare) = 06 Disabledorunabletowork(handicapped) = 05 Pregnancy 04 = Health reasons 03 = Waiting toberecalledformerjob = 02 Awaiting theseasonforwork 01 = Write theappropriatecodeinbox. REASONSFORNOTWORKING Census 2011 - A Mark theappropriate circle withanX. 3 =Donotknow 2 =No 1 = Yes 10 October? SEVEN DAYS before a businessinthe able tostart workor (name) allowed, would circumstances had been offeredor If asuitable jobhad WORK P-28 © Statistics South Africa, July 2010 Any response, Go toP-32 AVAILABLE TO 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow 3 Donotknow have been Glue area place of work ? TYPE OF SECTOR (name’s) (name’s) P-31 Is ...... 1 = In the formal sector 2 = In the informal sector 3 = household Private 4 = Do not know code Write the appropriate in the box. main task or duty in this or duty main task (name’s) (name’s) MAIN TASK/DUTY P-30 What is work? children, Selling fruit, Examples: Teaching cattle Bookkeeping, Feeding LETTERS only Use CAPITAL between words Do not leave spaces place of work or its (name’s) MAIN GOODS OR SERVICES P-29b What are the main goods or services What are the main goods produced at main functions? Car Construction, Examples: Real Estate, Hospitality Service Repairing, LETTERS only Use CAPITAL between words Do not leave spaces place of (name’s) Statistics South Africa, July 2010 South Statistics © INDUSTRY What is the name of work/organisation/company/business? Rapele Examples: Komani Hospital, Gold Mining Primary School, Harmony LETTERS only Use CAPITAL between words Do not leave spaces P-29a Census 2011 - A - Census 2011 SECTION F: EMPLOYMENT (continued) F: EMPLOYMENT SECTION Glue area SECTION G:FERTILITY- ASK OFWOMEN AGED 12-50 YEARS LISTEDONTHEFLAP Donotknow 3 = No 2 = Yes 1 = birth? soon after if thechilddied live child,even given birthtoa Has Mark the with anX. appropriate circle EVER BORN P-32 Go to H-01 Go to (name) CHILDREN If 2or3, 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot ever born? first child have her (name) age did At what BIRTH AT FIRST P-33 Example 2 AGE 5 alive? were born had that (name) children has How many EVER BORN CHILDREN P-34 Boys Total Girls Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Total Total Total Total Total Total Total Total Total Total Example TOTAL 0 1 0 ever 6 1 5 grown-ups? including household, with herinthis alive andliving children arestill (name’s How manyof HOUSEHOLD LIVING IN THE SURVIVING AND P-35 Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Boys Total Total Total Total Total Total Total Total Total Total Total Girls Example TOTAL ) 0 0 0 4 7 3 grown-ups? including elsewhere, living still aliveand children are (name’s How manyof ELSEWHERE AND LIVING SURVIVING P-36 Boys Total Girls Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Total Total Total Total Total Total Total Total Total Total Example TOTAL 0 0 0 ) 1 2 1 alive? no longer children are of How many ALIVE NO LONGER CHILDREN P-37 Boys Total Girls Boys Girls Boys Girls Boys Girls Boys Girls Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Total Total Total Total Total Total Total Total Total Total Example (name’s) TOTAL 0 0 0 1 2 1 after birth? child diedsoon even ifthe child born, (name’s) When was CHILD BORN P-38 MM MM MM MM MM MM MM MM MM MM Y Y YYY Y Y Y Y Y Y Y D D D D D D D D D D 205 1 0 Example LAST D D D D D D D D D D Y Y Y Y Y Y Y Y Y Y 4 0 9 last YY YY YY YY YY YY YY YY YY Mark the Donot = 3 Female = 2 Male = 1 female? born maleor last child Is BORN CHILD OF LAST P-39 X. circle withan appropriate (name’s know 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot SEX ) Mark the alive? born still last child Is X. circle withan appropriate Donot = 3 2=No 1=Yes ALIVE CHILD BORN P-40 Census 2011 - A Go to H-01 Go to (name’s If 1or3, know 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot know 3 Donot LAST ) © Statistics South Africa, July 2010 child borndie? (name’s When did BORN LAST CHILD DEATH OF P-41 MM MM MM MM MM MM MM MM MM MM Y Y Y Y Y Y Y Y YYY Y D D D D D D D D D D 207 1 0 Example D D D D D D D D D D Y Y Y Y Y Y Y Y Y Y 3 0 0 DATE OF ) last YY YY YY YY YY YY YY YY YY SECTION H: HOUSING, HOUSEHOLD GOODS AND SERVICES AND AGRICULTURAL ACTIVITIES - ASK OF EVERY HOUSEHOLD

H-01 TYPE OF LIVING QUARTERS H-04 TENURE STATUS What is the type of these living quarters? What is the tenure status of this household? 1 = Housing unit 1 = Rented 2 = Residential Hotel 2 = Owned but not yet paid off Write the appropriate 3 = Home for the aged 3 = Occupied rent-free code in the box. 4 = Converted hostel 4 = Owned and fully paid off 5 = Other If 2-4, Go to H-07 5 = Other Refers to the MAIN dwelling structure only and NOT to the land that it is situated Write the appropriate code in the box. on.

H-02 TYPE OF MAIN DWELLING H-05 ESTIMATED VALUE OF PROPERTY Which of the following best describes the MAIN dwelling and OTHER What would you estimate the market value or municipal valuation of dwelling(s) that this household occupies? this property to be? 01 = House or brick/concrete block structure on a separate stand or yard or on 1 = Less than R50 000 a farm 2 = R50 001 – R100 000 02 = Traditional dwelling/hut/structure made of traditional materials 3 = R100 001 – R200 000 Write the appropriate 03 = Flat or apartment in a block of flats 4 = R200 001 – R400 000 code in the box. 04 = Cluster house in complex 5 = R400 001 – R800 000 05 = Townhouse (semi-detached house in a complex) 6 = R800 001 – R1 600 000 06 = Semi-detached house 7 = R1 600 001 – R3 200 000 07 = House/flat/room in backyard 8 = More than R3 200 001 08 = Informal dwelling/shack in backyard 9 = Do not know 09 = Informal dwelling/shack not in backyard, e.g. in an informal/squatter settlement or on a farm H-06 AGE OF THE PROPERTY 10 = Room/flatlet on a property or a larger dwelling/servants’ quarters/ granny flat What is the age of this dwelling? 11 = Caravan/tent Main Other 01 = Less than one year 12 = Other dwelling dwelling 02 = 1 - 5 years 03 = 6 - 10 years 04 = 11 - 20 years 05 = 21 - 30 years Write the appropriate Write the appropriate code in the boxes. 06 = 31 - 40 years code in the box. 07 = 41 - 50 years H-02a CONSTRUCTION MATERIAL 08 = 51 - 60 years Glue area What is the main material used for the construction of the roof and wall 09 = 61 years or older of the MAIN dwelling? 10 = Do not know 01 = Brick 08 = Wattle and daub The age of the dwelling refers to when the building was completed, not the time 02 = Cement block/Concrete 09 = Tile of any later remodelling, additions or conversions. 03 = Corrugated iron/zinc 10 = Mud If the actual age is not known, give the best estimate. 04 = Wood 11 = Thatch/Grass 05 = Plastic 12 = Asbestos H-07 ACCESS TO PIPED WATER 06 = Cardboard 13 = Other 07 = Mud and cement mix In which way does this household mainly get piped water for household use? ROOF WALL 1 = Piped (tap) water inside the dwelling Write the appropriate 2 = Piped (tap) water inside the yard code in the box. 3 = Piped (tap) water on community stand: Write the appropriate codes in the boxes. distance less than 200m from dwelling 4 = Piped (tap) water on community stand: distance between 200m and 500m from dwelling H-03 ROOMS 5 = Piped (tap) water on community stand: distance How many rooms are there in the MAIN dwelling of this household? between 500m and 1000m (1 km) from dwelling 6 = Piped (tap) water on community stand: distance Dining rooms greater than 1000m (1 km) from dwelling 7 = No access to piped water Living rooms

Dining/Living room H-08 SOURCE OF WATER What is this household’s MAIN source of WATER for household Bedrooms Write the appropriate use? codes in the boxes. Study Rooms 1 = Regional/local water scheme (operated by municipality or other One room with multiple uses water services provider) 2 = Borehole Other rooms 3 = Spring Write the appropriate 4 = Rain water tank code in the box. Total Rooms 5 = Dam/pool/stagnant water 6 = River/stream 7 = Water vendor Exclude bathrooms and kitchen 8 = Water tanker Include garages if some members of the household are living in them 9 = Other If 2-9, Go to H-10

Census 2011 - A© Statistics South Africa, July 2010 SECTION H: HOUSING, HOUSEHOLD GOODS AND SERVICES AND AGRICULTURAL ACTIVITIES (Continued)

H-09 RELIABILITY OF WATER SUPPLY H-13 HOUSEHOLD GOODS AND SERVICES In the last 12 months, has this household had any interruptions in piped Does this household own any of the following in working order? water supply? 1 = Yes 1 Yes Write the appropriate code in the box. If 2, Go to H-10 2 = No 2 No Refrigerator Motorcar Mark the appropriate circle with an X. Electric/gas stove Television H-09a RELIABILITY OF WATER SUPPLY Vacuum cleaner Radio Did any specific interruption(s) in piped water supply last longer than two days ? Washing machine Landline/Telephone 1 Yes If 2, Go to H-10 Computer Cell phone 2 No

Mark the appropriate circle with an X. Music centre Mail Post box/bag DVD Player Mail box at residence H-09b ALTERNATIVE WATER SOURCE What alternative water source did the household use during water supply H-13a ACCESS TO INTERNET interruption? How does this household MAINLY access internet? 1 = Borehole 1 = From home 2 = Spring Write the 2 = From Cell phone 3 = Rain water tank appropriate 3 = From elsewhere other than home 4 = Dam/pool/stagnant water code in the Write the appropriate 4 = No access to internet 5 = River/stream code in the box. box. 6 = Water vendor 7 = Water tanker H-14 AGRICULTURAL ACTIVITIES 8 = Other 0 = None What kind of agricultural activity is the household involved in? (More than 1 activity can be chosen)

H-10 TOILET FACILITIES 1 = Livestock production (cattle, goats, sheep, pigs, etc) What is the MAIN type of TOILET facility used by this household? 2 = Poultry production (chicken, ducks, geese, guinea fowl, ostrich, etc) 1 = Flush toilet (connected to sewerage system) 3 = Vegetable production 2 = Flush toilet (with septic tank) 3 = Chemical toilet 4 = Production of other crops (grains, fruits, etc) Glue area 4 = Pit toilet with ventilation (VIP) Write the appropriate 5 = Pit toilet without ventilation code in the box. 5 = Fodder grazing/pasture/grass for animals 6 = Bucket toilet 7 = Other 6 = Other Mark the appropriate 0 = None 0 = None circle with an X.

If only 2-6, Go to H-14b. If 0, Go to M-00

H-11 ENERGY/FUEL H-14a LIVESTOCK What type of energy/fuel does this household MAINLY use for cooking, How many of the following does the household own? heating and lighting? 0 1 - 10 11 - 100 + 100 COOKING 1 = Electricity 6 = Candles 1 = Cattle 2 = Gas 7 = Animal Dung 2 = Sheep HEATING 3 = Paraffin 8 = Solar 4 = Wood 9 = Other 3 = Goats LIGHTING 5 = Coal 0 = None 4 = Pigs Write the appropriate code in the box. 5 = Other Note - Wood (4), coal (5) and animal dung (7) cannot be used for lighting Mark the appropriate circle with an X. - Candles (6) cannot be used for heating or cooking

H-12 REFUSE DISPOSAL H-14b PLACE OF AGRICULTURAL ACTIVITIES How is the refuse or rubbish from this household MAINLY disposed of? Where does this household operate its agricultural activities? 1 = Removed by local authority/private 1 = Farm land company at least once a week 2 = Removed by local authority/private 2 = Backyard or school company less often Write the appropriate 3 = Communal or tribal land 3 = Communal refuse dump code in the box. 4 = Own refuse dump 4 = Other 5 = No rubbish disposal 6 = Other Mark the appropriate circle with an X.

Census 2011 - A© Statistics South Africa, July 2010 Glue area 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No POSTNATAL (the deceased) Mark the appropriate circle with an X. M-08 DEATH Did die within 6 weeks delivery? after Yes 1 = 2 = No 3 = Do not know die 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No DEATH (the deceased) Mark the appropriate circle with an X. while giving birth? Yes 1 = 2 = No 3 = Do not know M-07 DURING BIRTH Did TIME OF DEATH 12 - 50 YEARS AT THE AT YEARS 12 - 50 If 1 to M-06 or M-07, Questionnaire completed 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 3 Do not know 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 2 No 2 No 2 No 2 No 2 No PREGNANT (the deceased) ASK ONLY OF DECEASED WOMEN ASK ONLY M-06 TIME OF AT DEATH Did die while pregnant? Yes 1 = 2 = No 3 = Do not know Mark the appropriate circle with an X. ? (the 1 Unnatural 1 Unnatural 1 Unnatural 1 Unnatural 1 Unnatural 1 Unnatural 1 Unnatural 1 Unnatural 2 Natural 2 Natural 2 Natural 2 Natural 2 Natural 2 Natural 2 Natural 2 Natural CAUSE (e.g. violence or accident) 1 = Unnatural death 2 = death Natural M-05 OF DEATH What caused the death of deceased) Mark the appropriate circle with an X. NUMBER OF DEATHS age in (the How many members of the How many members of in the away household passed 9 last 12 months (between October 2010 and 9 October 2011)? M-00a AGE M-04 OF THE DECEASED What was deceased’s) completed years at the time of death? Write the age in the box. If age is less than 1 year, write 00. male or

1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 1 Male 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female 2 Female SEX OF (the appropriate THE DECEASED M-03 Was deceased) female? 1 = Male 2 = Female Mark the circle with an X. appropriate Mark the circle with an X. THANK YOU FOR YOUR CO-OPERATION death? YY YY YY YY YY YY (the

MONTH Y Y Y Y Y Y Y Y Y YYY Y Y YYY Y Y Y MM MM MM MM MM MM MM MM Write the month and year in the appropriate boxes. M-02 AND YEAR OF DEATH What was the MONTH and the YEAR of deceased’s) deceased’s) 3 Do not know 1 Yes 2 No If 2 or 3, Questionnaire completed If 2 or 3, Questionnaire Statistics South Africa, July 2010 South Statistics © ? (the

If more than 8 deaths in the household, use a second questionnaire. Write the barcode of the 1st questionnaire below: If more than 8 deaths in the household, use a second questionnaire. Write NAME DEATH OCCURRED DEATH M-00 away in the household passed Has any member of this 9 October 2010 and 9 October last 12 months (between 2011)? deceased) Use CAPITAL LETTERS only What was the first name of M-01 OF DECEASED Census 2011 - A - Census 2011 SECTION I: MORTALITY IN THE LAST 12 MONTHS IN THE I: MORTALITY SECTION ENUMERATION AREA NUMBER

PROVINCE ......

LOCAL MUNICIPALITY ......

MAIN PLACE ......

SUB PLACE ......

TYPE OF PLACE Airport Border post Harbour Tourist Hotel Other Mark the appropriate circle with an X.

SDI NUMBER

NAME OF THE PLACE ......

MAP REFERENCE NUMBER LISTING RECORD NUMBER

METHOD OF QUESTIONNAIRE COMPLETION - Mark the appropriate circle with an X A fieldworker through an Interview Respondent through self-enumeration FIELD STAFF Fieldworker ID No. Supervisor ID No.

Signature ...... Signature......

STATISTICS ACT NO. 6 OF 1999 (CONFIDENTIALITY)

17(1) Despite any other law, no return or other information collected by Statistics South Africa for the purposes of official or other statistics that relates to an individual or a household may be disclosed to any person.

18(1e) & 18(1g) Any officer of Statistics South Africa who wilfully discloses any data or information obtained in the course of such employment to a person not authorised to receive that information is guilty of an offence and liable on conviction to a fine not exceeding R10 000, or to imprisonment for a period not exceeding 6 months or to both.

PROCEDURES OF ENUMERATION Who should complete this questionnaire? - All persons who will be in transit (departing) at airports, harbours, border posts, people in tourist hotels, camping sites, caravan parks, the homeless (not in a shelter) and mobile populations (midnight 9 - 10 October 2010).

- Parents travelling with children should fill in a separate questionnaire for each child.

How to complete the questionnaire - Read every question carefully. - For questions where a choice of answers is provided, the fieldworker/respondent should write the appropriate codes in the boxes. - Make sure that all the codes are written inside the boxes. For example: Correct3 Incorrect 3

For open-ended questions, write legibly in CAPITAL LETTERS in the boxes provided. For example Jacob Maluleke should be written as:

J ACO B M A LULEKE

SHOULD YOU ENCOUNTER ANY DIFFICULTIES IN THE COMPLETION OF THE QUESTIONNAIRE, PLEASE CONTACT:

...... ON ......

OR PHONE THE CENSUS HOTLINE, TOLL FREE, ON ......

Census 2011 - B1© Statistics South Africa, July 2010 (F-01) What is your name / name and surname / initials? Use CAPITAL LETTERS only

(F-02) What is your age in completed years? For babies less than 1 year write 000 for age. For persons 7 years and 10 months write 007 for age.

(F-03) Are you male or female?

1 Male Mark the appropriate circle with an X. 2 Female

(P-01) What is your date of birth?

D DMMY Y Y Y

(P-03) What is your PRESENT marital status? 1 = Married 2 = Living together like married partners 3 = Never married Write the appropriate code in the box. 4 = Widower / widow 5 = Separated 6 = Divorced

(P-05) How would you describe yourself in terms of population group? 1 = Black African 2 = Coloured 3 = Indian or Asian Write the appropriate code in the box. 4 = White 5 = Other

(P-07) In which province were you born? 01 = Western Cape 06 = North West 02 = Eastern Cape 07 = Gauteng Write the appropriate code in the box. 03 = Northern Cape 08 = Mpumalanga 04 = Free State 09 = Limpopo 05 = KwaZulu Natal 10 = Outside South Africa If 01-09, Go to P-09

(P-08a) If you are born outside the country, in which year did you move to South Africa? If moved more than once into South Africa, please indicate the year of last move.

Y Y Y Y

(P-09) Are you a South African citizen?

1 Yes Mark the appropriate circle with an X. 2 No

(P-10a) In which province do you usually live for at least four nights a week and have done so for the last six months?

01 = Western Cape 06 = North West 02 = Eastern Cape 07 = Gauteng Write the appropriate code in the box. 03 = Northern Cape 08 = Mpumalanga 04 = Free State 09 = Limpopo If 10, Questionnaire complete 05 = KwaZulu Natal 10 = Outside South Africa

(P-10c) In which city/town do you usually live or what is the nearest city/town? Use CAPITAL LETTERS only

Thank you for your co-operation

Census 2011 - B1© Statistics South Africa, July 2010 Glue area

FOR STATISTICAL USE ONLY PROCEDURES OF ENUMERATION ENUMERATION AREA NUMBER Who should be enumerated/counted on this questionnaire? PROVINCE ...... - Individuals who will be accommodated in an institution (for example, student residences, LOCAL MUNICIPALITY ...... boarding schools, frail care centres, hospitals, defense force/army barracks, police cells, prisons, unconverted hostels, shelter for the homeless/refugees/other shelters, initiation schools, MAIN PLACE ...... convents/monasteries, orphanages, homes for the disabled and old age homes - depending on the arrangement) on reference night should be enumerated. SUB PLACE ...... - Include babies born before midnight between 9 - 10 October 2010 - Hotel managers/administration should complete the section on services and the fieldworker to PARTICULARS OF THE INSTITUTION complete the other sections SDI number How to complete the questionnaire Name of the institution ...... - Read every question carefully - For questions where a choice of answers is provided, the fieldworker/respondent should write Block / Ward ...... the appropriate codes in the boxes - Make sure that all the codes are written inside the boxes. For example Physical identification of the institution ...... Correct3 Incorrect 3 ...... For numeric values such as age, the fieldworker/respondent should Postal code 7 write the correct answer in the box as a number (e.g. “007”): 00 Telephone number Questionnaire of completed for this institution. Number of persons in the institution Total Male Female

If more than 250 persons in the institution, write the barcode of the 1st questionnaire below:

Map Reference Number Listing Record Number

FIELD STAFF Fieldworker ID No. Supervisor ID No.

Signature ...... Signature ......

SHOULD YOU ENCOUNTER ANY DIFFICULTIES IN THE COMPLETION OF THE QUESTIONNAIRE, PLEASE CONTACT ...... ON ...... OR PHONE THE CENSUS HOTLINE, TOLL FREE ON ......

Census 2011 - C1© Statistics South Africa, July 2010 (H-01) What type of collective living quarter is this? (H-11) What type of energy/fuel does this institution MAINLY use for cooking, heating and 01 = Hospital/medical facility/clinic lighting? 02 = Prison/correctional institution/police cells 1 = Electricity 03 = Defense force barracks 2 = Gas 04 = Frail care centres 3 = Paraffin 05 = Refugee camp/shelter 4 = Wood COOKING 06 = Covent/monastery Write the appropriate 5 = Coal Write the appropriate 07 = Community or church hall code in the box. 6 = Candles HEATING code in the box. 08 = Unconverted hostel 7 = Animal dung 09 = Student residence/boarding school 8 = Solar LIGHTING 10 = Tourist hotel 9 = Other 11 = Other 0 = None

(H-07) In which way does this institution mainly get piped water for use? Note 1 = Piped (tap) water inside the institution - Wood (4), coal (5) and animal dung (7) cannot be used for lighting 2 = Piped (tap) water inside the yard - Candles (6) cannot be used for heating or cooking 3 = Piped (tap) water on community stand: distance less than 200m from institution (H-12) How is the refuse or rubbish from this institution MAINLY disposed of? 4 = Piped (tap) water on community stand: Write the appropriate 1 = Removed by local authority/private distance between 200m and 500m from institution code in the box. company at least once a week 5 = Piped (tap) water on community stand: distance 2 = Removed by local authority/private between 500m and 1000m (1 km) from institution company less often Write the appropriate 6 = Piped (tap) water on community stand: distance 3 = Communal refuse dump code in the box. greater than 1000m (1 km) from institution 4 = Own refuse dump 7 = No access to piped water 5 = No rubbish disposal 6 = Other (H-08) What is this institution’s MAIN source of WATER for domestic use? 1 = Regional/local water scheme (operated by municipality or other water services provider) 2 = Borehole (H-13) Does this institution own any of the following in working order? 3 = Spring 1 = Yes 4 = Rain water tank Write the appropriate 2 = No 5 = Dam / pool/ stagnant water code in the box. 6 = River / stream Television 7 = Water vendor 8 = Water tanker Radio 9 = Other Write the appropriate (H-10) What is the MAIN type of TOILET facility used by this institution? Landline telephone code in the box. 1 = Flush toilet (connected to sewerage system) 2 = Flush toilet (with septic tank) Refrigerator 3 = Chemical toilet Write the appropriate 4 = Pit toilet with ventilation (VIP) code in the box. Internet facilities 5 = Pit toilet without ventilation 6 = Bucket toilet 7 = Other 0 = None

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

LIST OF PERSONS IN THIS INSTITUTION ON CENSUS NIGHT F-00 Person F-01 Name/Name and surname/initials P-01 Date of birth F-02 Age in F-03 Sex P-05 Population P-03 Marital status Barcode Number number completed years group Example Example 1 = Male 1 = Black African 1 = Married Use the corresponding barcode from 2 = Female 2 = Coloured 2 = Living together like married partners questionnaire B if the same person 1 2 3 = Indian or Asian JOHN MALULEKE Example 4 = White 3 = Never married is completed in both 4 = Widower/Widow Write the 0 3 0 29 Mark the 5 = Other appropriate appropriate 5 = Separated code in the circle with an X. Write the appropriate 1 9 81 code in the box. 6 = Divorced box.

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010 LIST OF PERSONS IN THIS INSTITUTION ON CENSUS NIGHT F-00 Person F-01 Name/Name and surname/initials P-01 Date of birth F-02 Age in F-03 Sex P-05 Population P-03 Marital status Barcode Number number completed years group Example 1 = Male 1 = Black African 1 = Married Use the corresponding barcode from Example 2 = Female 2 = Coloured 2 = Living together like married partners questionnaire B if the same person 1 2 3 = Indian or Asian Example 4 = White 3 = Never married is completed in both JOHN MALULEKE 4 = Widower/Widow Write the 0 3 0 29 Mark the 5 = Other appropriate appropriate 5 = Separated code in the circle with an X. Write the appropriate 1 9 81 code in the box. 6 = Divorced box.

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D

2 M M 1 Male Y Y YY 2 Female

D D

3 M M 1 Male Y Y YY 2 Female

D D

4 M M 1 Male Y Y YY 2 Female

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D

2 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 7 M M 1 Male Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

D D

9 M M 1 Male Y Y YY 2 Female

D D

0 M M 1 Male Y Y YY 2 Female

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

D D

7 M M 1 Male Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 3 M M 1 Male Y Y YY 2 Female

D D 4 M M 1 Male Y Y YY 2 Female

D D

5 M M 1 Male Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

D D

3 M M 1 Male Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D

0 M M 1 Male Y Y YY 2 Female

D D

1 M M 1 Male Y Y YY 2 Female

D D

2 M M 1 Male Y Y YY 2 Female

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 6 M M 1 Male Y Y YY 2 Female

D D

7 M M 1 Male Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

D D

5 M M 1 Male Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 M M 1 Male Y Y YY 2 Female

D D

2 M M 1 Male Y Y YY 2 Female

D D

3 M M 1 Male Y Y YY 2 Female

D D

4 M M 1 Male Y Y YY 2 Female

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

D D

9 M M 1 Male Y Y YY 2 Female

D D

0 M M 1 Male Y Y YY 2 Female

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D

4 M M 1 Male Y Y YY 2 Female

D D

5 M M 1 Male Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

D D

3 M M 1 Male Y Y YY 2 Female

D D

4 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010

Glue area Glue area

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 0 M M 1 Male Y Y YY 2 Female

D D

1 M M 1 Male Y Y YY 2 Female

D D

2 M M 1 Male Y Y YY 2 Female

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D

0 M M 1 Male Y Y YY 2 Female

Glue area Glue area

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D 8 M M 1 Male Y Y YY 2 Female

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

Glue area Glue area

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D 2 M M 1 Male Y Y YY 2 Female

D D

3 M M 1 Male Y Y YY 2 Female

D D

4 M M 1 Male Y Y YY 2 Female

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

D D

1 M M 1 Male Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

Glue area Glue area

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D

0 M M 1 Male Y Y YY 2 Female

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

Glue area Glue area

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M 2 Female Y Y YY

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M Y Y YY 2 Female

D D 1 Male 1 M M Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M Y Y YY 2 Female

D D 1 Male 4 M M Y Y YY 2 Female

Glue area Glue area

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M 2 Female Y Y YY

D D 1 Male 7 M M 2 Female Y Y YY

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

D D

1 M M 1 Male Y Y YY 2 Female

D D 1 Male 2 M M Y Y YY 2 Female

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M 2 Female Y Y YY

D D 1 Male 5 M M 2 Female Y Y YY

D D 1 Male 6 M M Y Y YY 2 Female

D D 1 Male 7 M M Y Y YY 2 Female

D D 1 Male 8 M M Y Y YY 2 Female

D D 1 Male 9 M M Y Y YY 2 Female

D D 1 Male 0 M M Y Y YY 2 Female

Glue area Glue area

D D 1 Male 1 M M 2 Female Y Y YY

D D 1 Male 2 M M 2 Female Y Y YY

D D 1 Male 3 M M 2 Female Y Y YY

D D 1 Male 4 M M Y Y YY 2 Female

D D 1 Male 5 M M Y Y YY 2 Female

D D

6 M M 1 Male Y Y YY 2 Female

D D

7 M M 1 Male Y Y YY 2 Female

D D

8 M M 1 Male Y Y YY 2 Female

Census 2011 - C1© Statistics South Africa, July 2010 LIST OF PERSONS IN THIS INSTITUTION ON CENSUS NIGHT F-00 Person F-01 Name/Name and surname/initials P-01 Date of birth F-02 Age in F-03 Sex P-05 Population P-03 Marital status Barcode Number number completed years group Example Example 1 = Male 1 = Black African 1 = Married Use the corresponding barcode from 2 = Female 2 = Coloured 2 = Living together like married partners questionnaire B if the same person 1 2 3 = Indian or Asian Example JOHN MALULEKE 4 = White 3 = Never married is completed in both 4 = Widower/Widow Write the 0 3 0 29 Mark the 5 = Other appropriate appropriate 5 = Separated code in the circle with an X. Write the appropriate 1 9 81 code in the box. 6 = Divorced box.

D D 1 Male 9 M M 2 Female Y Y YY

D D 1 Male 0 M M 2 Female Y Y YY

Comments and full details of all non-response / unusual circumstances

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Census 2011 - C1© Statistics South Africa, July 2010 Census 2011 Dress Rehearsal Census 2011 Dress Rehearsal Census 2011 Dress Rehearsal