REPUBLIC OF COSTA RICA X NATIONAL POPULATION CENSUS AND VI HOUSING CENSUS SECTION I: LOCATION Registration Area Smallest Statistical Unit Dwelling Household This mark applies only If this form is a CONTINUATION of after the second form the same HOUSEHOLD, check here: in households with more than 6 people. Address District FILLING INSTRUCTIONS RIGTH WRONG Mark well Do not mark well SECTION II: CHARACTERISTICS OF THE DWELLING 1. Observe, probe and check the type of dwelling 4. The exterior walls are mainly . INDIVIDUAL . cinder block or brick? . 1 Independent house . 1 . concrete base and wooden top or Fibrolit? . 2 Independent house in condominium . 2 . wood? . 3 Apartment building . 3 . prefabricated or tiles? . 4 Condominium apartment building . 4 . Fibrolit, Ricalit? (asbestos cement sheet .) . 5 Traditional Indigenous Dwelling (palenque or ranch) 5 . natural fibers? (bamboo, cane, chonta) . 6 Room in shared house or building old (“cuartería”) 6 . waste material? . 7 Hovel or shack (“tugurio”) . 7 Other (zinc, adobe) . 8 Other (store, mobile home, boat, truck) . 8 5. The roof is mainly . COLLECTIVE Worker‘s house . 9 . zinc? . 1 . Fibrolit, Ricalit or cement? (fibrocement) . 2 Children’s shelter . 10 Skip to Nursing homes . 11 SECTION . natural material? (palm, straw or other suita) . 3 III, ques. 3 . waste material? . Jail . 12 4 Other (clay tile, etc) . Other (guest house, “pensión”, convent) . 13 5 Skip to 6. Does the dwelling have interior ceiling paneling? HOMELESS . 14 SECTION IV Yes . 1 No . 2 2. Inquire and check if the dwelling is occupied or unoccupied 7. The floor is mainly . OCCUPIED ... ceramic tile, linoleum flooring, terrazzo tile? . 1 1 Occupied with usual residents present . ... cement? (ocher, such as brushed or not) . 2 2 Return Occupied with usual residents absent . later ... wood? ................................... 3 … natural material? (chonta or log) ............ UNOCCUPIED 4 Other material .............................. For rent or sale . 3 5 Earth/Ground Floor . Under construction or repair . 4 6 End of the Seasonal for vacation . 5 questionnaire 8. Does the state of the… Seasonal for workers or students . 6 Poor? Fair? Good? Other . 7 … exterior walls is… 1 2 3 … roof is . 1 2 3 3. Is this dwelling . … floor is . 1 2 3 . owned and completely paid for? . 1 9. How many bedrooms, exclusively for sleeping, does the dwelling have? . owned and being paid for in installments? . 2 . rented? . 3 0 1 2 3 4 5 6 7 8 9 10 . provided for work purposes? . 4 or more . provided for Other reason? (no pay) . 5 10. Including bedrooms exclusively for sleeping, how many rooms total . in squatter? (“en precario”) . 6 does this dwelling have? (excluding bathrooms or laundry room) Other . 7 1 2 3 4 5 6 7 8 9 10 or more 1 Continued . SECTION II: CHARACTERISTICS OF THE DWELLING 11. Does dwelling water come from . 17. In this dwelling, do you separate from the rest of the garbage the… . a rural or communal aqueduct? (ASADAS or CAAR) . 1 Sí No . a municipal aqueduct? . 2 … plastic, glass, aluminum? . 1 2 . an aqueduct of AyA? (Acueductos y Alcantarillados) 3 … paper? . 1 2 . an aqueduct of a company or cooperative? . 4 . a well? . 5 … leftovers? (fruits, vegetables, shells, bones) 1 2 . a river or stream? . 6 Other source (rain, water truck, fire hydrant) . 7 -18. In this dwelling, do you have… . Yes No Does the water come from pipe inside the dwelling? 12. .... radio or stereo? .................... 1 2 Yes . 1 No . 2 ... fixed telephone line? . 1 2 13. Is the toilet connected to . ... TV screen? (plasma, LCD or LED) . 1 2 . sanitary sewer? . 1 . septic tank? . 2 ... conventional TV? . 1 2 . has direct access to canal, ditch, river or stream? . 3 ... cable or satellite?................... 1 2 . or pit toilet or latrine? . 4 Does not have a toilet . 5 ... hot water system for whole house? . 14. Does dwelling electricity comes from… 1 2 … ICE or CNFL? . 1 ... water storage tank?................. 1 2 . ESPH or JASEC? . 2 . a cooperative? . 3 ... desktop computer? . 1 2 . solar panel? . 4 ... laptop?............................ Other source? . 5 1 2 There is no electricity . 6 ... Internet? . 1 2 In this dwelling, do you cook mainly with . 15. ... car? (not for work) . 1 2 . electricity? . 1 ... motorcycle? (not for work) . gas? . 2 1 2 . wood or charcoal? . 3 Other . 4 19. How many mobile phone lines have in this dwelling? None (no cooking) . 5 16. Do you eliminate trash mainly by . 0 1 2 3 4 5 or more, wrote . a garbage truck? . 1 20. Home phone number or mobile: . throwing in a hole or burying? . 2 . burning it? . 3 . throuwing away in a derelict land? . 4 . throwing into a river, stream or sea? . 5 Other . 6 FILLING INSTRUCTIONS RIGTH WRONG Mark well Do not mark well 2 SECTION III: HOUSEHOLD CHARACTERISTICS 1. How many people live here in this dwelling? ENUMERATOR: Find out if all people have six months or more to live here, or To t a l if any of them have less time, but plan to stay to live in this dwelling. 2. Do all people who live here share a budget and prepare food in common? Yes . A single Household Skip to 3 No . So, how many households are in the dwelling? ENUMERATOR: when you finish the interview of Household 1, open a new form for each additional household, transcribe Section I, changing the number of households as appropriate 2 3 4 5 6 or more (2.3, ...) and skip to Section III question 3. HOUSEHOLD LIST OF PERSONS 3. What are the names and surnames of every person in this HOUSEHOLD, beginning with the head or reference person? Sex Person No Full Name Male Female 01 ENUMERATOR: Continue with other 02 people, according to relationship to the person 01 in the following order: 03 04 - husband, wife or partner, - single sons or daughters, 05 - married children, her/his partner 06 and their children 07 - other relatives 08 - domestic staff and their relatives 09 - Other non-relatives. 10 11 12 ENUMERATOR: If this HOUSEHOLD has more than 12 people open a new form, transcribe SECTION I, mark the oval indicating the continuation of the same household and continue filling out the list. 5. So, how many people are in this household? JUST FOR COLLECTIVE DWELLING 4. ENUMERATOR: If the 6. How many people live here at this group home? informant told you M a l e s that the leadership at M a l e s dwelling is shared with Females partners, CHECK HERE Females Total Skip to Total SECTION IV 7. Is any member of this home living in another country? Yes . 1 How many? No . 2 1 2 3 4 5 or more, wrote 8. In the last year, did anyone in this household… Sí No … receive money or assets from someone who lives abroad, for use by this household? . … sent money or assets to any person living abroad, for use of that household?............... 9. Anyone in this household . … has agricultural field or farm? . 1 … planted crops during the past year? (on land owned, rented, loaned) . 2 … has cattle, pigs, chickens, ducks, turkeys, geese, other? (for sale or own consumption) . 3 None of the above . 4 3 SECTION IV: SOCIOECONOMICAL CHARACTERISTICS Person N° Name FOR ALL INDIVIDUALS 10. (Name) considers himself/herself… 1. What relation has (name) with (person No 01)? ... black or … White or afrodescendent? . 1 mestizo? . 4 Head................ 1 Brother-in-law or Other .............. 5 Spouse or partner . 2 sister-in-law........ 7 … mulatto? ......... 2 None .............. 6 Son, daughter, stepson Parent . 8 … Chinese? . 3 or stepdaughter . 3 Parent-in-law . 9 Son-in-law or Other relative....... 10 11. What kind of social security/insurance does (name) have? daughter-in-law ...... 4 Domestic servantsand Salaried . 1 Grandchild . 5 their relatives . 11 Self-employed, voluntary or by agreement . 2 Brother or sister . 6 Other non-relative... 12 Non-contributory (receives annuity) . 3 2. (Name) is male or female? State retirement pensions CCSS, Magisterio or Other . 4 Family insured . 5 Male . 1 Female . 2 Insured by the State (State account) . 6 3. How old is (name)? Other . 7 No social security/insurance from the CCSS . 8 Under one year . 0 Year . 12. Does (name) have any permanent limitation… You can mark multiple options 4. What is (name) date of birth? … seeing even wearing glasses or contact lens? . 1 Day Month Year … hearing? . 2 … talking? . 3 5. When (name) was born, where did his/her mother live? … walking or climbing stairs? . 4 In this canton . 1 Skip to 7 … using arms or hands? . 5 … of intellectual type? (retardation, Down syndrome, etc) 6 In another canton . 2 Which canton? … of mental type? (bipolar, schizophrenia, etc) . 7 None of the others . 8 Skip to 7 13. Is (name) attending at . … day care, nursery or preschool?.................... 1 Which province? 2 1 2 3 4 5 6 7 … kindergarten or primary school, school or high school? San José Alajuela Cartago Heredia Guanacaste Puntarenas Limón … “open education”? (takes test from the MEP) . 3 … paraunversitary or university? . 4 In another country . 3 … special education?................................ 5 Which country? … day care center for elderly? . 6 Skip Nicaragua United States Colombia El Salvador Panamá Cuba Not attending ...................................... 7 to 15 Other country 14. The institution that (name) attends is . … public? . 1 … private or semioffical? . 2 6. Which year did (name) arrived to live Costa Rica? FOR THOSE WHO have 5 yEARS OR OLDER If you don´t know the year ask 15. (Name) is able to read and write? (Name) arrived to Costa Rica Yes . 1 No . 2 … before 1980? 1 … between 1990 and 1999? 3 … between 1980 and 1989? 2 … since 2000 or then? 4 16. What is the highest grade or year that (name) completed? Level No degree .