Number of persons in large dwelling before it was split

Number of persons in large household before it was split

Donated dwelling

Donation strata: strata number

____ Place ____ Parish _ _ _ Section number _ _ _ Building number _ _ Dwelling number

Size of place of residence

A. Type of living quarter If options 11, 49 or 58 were selected, end the questionnaire here.[skip questions B, 1-13] [] 11 On board population and diplomatic personnel [] Housing unit: [] 22 Conventional dwelling (house, apartment, country house, and similar) [] 33 Shack (tin neighborhood style) [] 34 Rudimentary wooden house [] 35 Mobile housing unit (roullote, tent, boat, RV, etc.) [] 36 In a permanent building not designed for habitation (granaries, garages, shops, offices, etc.) [] 37 Other place not intended for inhabitation (cave, staircase, bridge, etc.) [] Collective living quarter [] 49 Hotel, boarding house, or similar (tourism complex, camping parks, etc.) [] Camps or Institutions [] 51 Social support (asylum, orphanage, etc.) [] 52 Education (school, religious seminar, dormitories, boarding school, etc.) [] 53 Military (barracks or military base) [] 54 Prison (jail or similar) [] 55 Religious (convent, monastery, etc.) [] 56 Health (hospital, recovery home, etc.) [] 57 Work (personnel dormitory, camp, etc.) [] 58 Other type

B. Occupancy status [Question B was asked in case of housing units and collective living quarters, except hotels or similar and institutions of "other type", per question A] If options 3, 4, 5, 6, or 7 in question B [is] selected, end the questionnaire here. If option 2 [is] selected and there is no dwelling, end this questionnaire likewise. [] Occupied [] 1 Usual residence [] 2 Seasonal use [] 3 Absent occupant (emigrant, etc.) [] Vacant [] 4 For sale [] 5 For rent [] 6 For demolition [] 7 In ruins or other cases

B. Occupancy status [Question B was asked in case of housing units and collective living quarters, except hotels or similar and institutions of "other type", per question A] If options 3, 4, 5, 6, or 7 in question B [is] selected, end the questionnaire here. If option 2 [is] selected and there is no dwelling, end this questionnaire likewise. [] Occupied [] 1 Usual residence [] 2 Seasonal use [] 3 Absent occupant (emigrant, etc.) [] Vacant [] 4 For sale [] 5 For rent [] 6 For demolition [] 7 In ruins or other cases

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] 2. Electricity Does the housing unit have electricity? [] 1 Yes [] 3 No

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] 3. Water (Water supply system) [] Piped water available in the housing unit: [] 1 From a public network [] 2 From a private source [] 3 Piped water available within the building but outside the housing unit [] No piped water available inside the dwelling or the building, but the main source of water is: [] 4 Public drinking fountain [] 5 Private well or hole [] 6 Public well with pump [] 7 Public well without pump or surface water fountain

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] 4. Toilet facilities Indicate if the housing unit has: [] 1 No toilet available [] 3 Has toilet with flush device [] 5 Has toilet without flush device

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] 5. Bath or shower facilities By bath or shower facilities we mean any facility that is permanently connected to the a sewer and draining system that allows for the evacuation of black waters outside the dwelling. Does the housing unit have a fixed system of bath or shower? [] 1 Yes [] 3 No

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] 6. Sewage disposal system: [] 2 Housing unit without sewage disposal system [] Housing unit with sewage disposal system: [] 4 Connected to a public sewage disposal plant [] 6 Connected to a private sewage disposal plant (septic tank, etc.) [] 8 Other sewage arrangements (open pit, ditches, brook, etc.)

[Questions 1-13 were asked in cases of a housing unit or a collective living quarter, except hotels or similar and institutions of "other type" -- that is occupied as a usual residence or for seasonal use, per questions A, B] If your dwelling is a tent, rudimentary timber house, mobile home, temporary or improvised home, end this questionnaire. [skip questions 7-13] [Questions 7-13 were asked in cases of a housing unit or a collective living quarter (except hotels or similar and institutions of "other type"), that is occupied as a usual residence or for seasonal use, and is not a tent, rudimentary timber house, mobile home, temporary or improvised home, per questions A, B.] 7. Kitchen Indicate if the housing unit: [] 1 Does not have kitchen [] 2 Does not have a kitchen, but has a kitchenette or a small space destined and prepared to cook [] 3 Has kitchen