From
To
Name____
Serial number of household member ____
Q.1 Relation to the head of household1 Head of household2 Husband/wife3 Children4 Son/daughter in law5 Grandchild6 Parent/parent in-law7 Other relative8 Housemaid9 Other
Q.2 Sex1 Male2 Female
Q.3 Age____ years old
Q.4 Marriage status1 Single2 Married3 Divorced4 Widowed
Q.5 Religion1 Muslim2 Protestant/other Christian3 Catholic4 Hindu5 Buddhist6 Other religion
Q.6 Citizenship1 Indonesian citizen2 People's Republic of China (PRC), Taiwan, and stateless China citizen3 Other foreign citizen
Q.7 Place of birthProvince ____Regency/municipality ____
Q.8 Ever lived in another regency/municipality1 Yes2 No
Q.9 Duration of time living in the current regency/municipality____years
Q.10 Previous residenceProvince ____Regency/municipality ____
Q.11 Reason moved1 Transmigration2 Employment3 Education4 Other
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