From
To
2. Sex[] 1 Male[] 2 Female
3. Own mother living in this household?[] 1 Yes[Question 4 was asked only of those persons who responded "Yes" in question 3.]4. Serial number _ _[] 2 No (go to question 5)
5. Age_ _ years
6. Month and year of birth known?[] 1 Yes[] 2 No (go to question 8)
7. Month and year of birth[Question 7 was asked of persons who know their month and year of birth, per question 6.]Month ____Year 19 _ _
8. Marital status[] 1 Single (not yet married)[] 2 Married[] 3 Widowed[] 4 Divorced
9. Religion[] 1 Muslim[] 2 Protestant/other Christian[] 3 Catholic[] 4 Hindu[] 5 Buddhist[] 6 Other
10. Citizenship[] 1 Indonesian[] 2 Chinese (People's Republic of China, Taiwan, Stateless)[] 3 Other foreigner
11. Place of birthProvince ____
12. Duration of residence in present provinceYears _ _
13. Place of previous residenceProvince ____
14. Place of residence 5 years agoProvince ____
15. Have you felt unwell during the past week?[] 1 Yes[] 2 No (go to question 17)
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