I
PLACE NO
..........
/SUBSIDIARY\-/
MAIN\
IN TH; NAME OF ALLAH
THE COMPASSIO~ATEAND THE MERCIFUL
NAME OF
SERIAL NO. OF THE HOUSEHOLD IN THE LISTING F
O
R
M
\
/
REGULAR SETTLED
HOUSEHOLD
U
REGULAR UNSETTLED
HOUSEHOLD
IAME & FAMILY NAME RELATIONSHIP *
OF HOUSEHOLD
TO HEAD OF
MEMBERS
HOUSEHOLD
SEX
DATE OF
BIRTH
TO BE COMPLETED FOR EACH PERSON
AGE
RELIGION
RESIDENTIAL STATUS & SECT
CITIZENSHIP
~ ~ ~ ~2 ~ ~
SONIDAUGHTER 3
MALE
GRAIJD-CHILD/
1
GREAT GRANDCHILD
, 5
FATHER/
FEMALE
o
L
'RESENT
D
SON ID AUG HT ER^
ro BE COMPLET
I
I
LANGUAGE
I
I
PHYSICAL DISABILITIES
RELATIVES
1
TEMPORARILY
4BSENT
2
AGE
(IMPOSED WAR)
CAPTIVE
3
LAST
(IMPOSED WAR)
4
'IRTHDA MISSING
8
LIVING
4BROAD
5
DTHER
6
PLACE Of"
BIRTH
SAME CITY
OR
VILLAGE
1
OTHER
PLACE:
CITY
2
VILLAGE
3
ABROAD
4
1 FOR PRESENT & TEMPORARILY
2BSENT MEMBER (CODED 1 & 2 IN COLUMN 8 )
O BE COMPLETEI ro BE COMPLETED FOR MEMBERS
OR CODES 2,3t $HOSE DURATION OF RESIDENCE
IN COLUMN It 4s STATEI) IN COLUMN 17, IS
LESS THAN 10 YEARS
PLACE OF
FOR CODES
PREVIOUS
3,4 & 5 IN
RESIDENCE
COLUMN 18
ELSEWHERE
IN THE SAME SHAHRESTAN
DURATION OF
RESIDENCE IN SHAHRESTAN: OF PREVIOUS
RESIDENCE
THIS CITY OR CITY
1
( 'IF NOT
VILLAGE (IN VILLAGE 2
PREVIQUSLY
FULL YEARS )
RESIDING IN
OTHER
SHAHRESTAN: IRAN, NAME
OF THE
CITY
3
FOREIGN
VILLAGE 4
COUNTRY )
ABROAD
8
5
NUMBER OF
HOUSEHOLD MEMBERS
U
U
BLOCK NO./NAME
OF VILLAGE
I
HEAD OF
FOR THE NEWLY
BORN BABIES NOT
YET NAMED, WRITE
"INFANT BOY" OR
IIINFANTGIRL"
AS THE CASE MAY
BE, BEFORE THE
FAMILY NAME
DISTRICT NO.
----_-___-___-
REGION NO.
STATISTICAL CENTRE OF IRAN
-
SECTION NO.
DEHESTAN
ISLAMICREPUBLIC OF IRAN
MINISTRY OF PLAN AND BUDGET
TYPE OF HOUSEHOLD:
SHAHR (CITY)
1
u
l
l
II
NAME OF SHAHRESTAN
16
17
18
1
J
TO BE COMPLETED FOR PERSONS 6 YEARS OF AGE
EDUCATION
-
& LITERACY
OVER
TO BE COMPLETED FOR THE
LITERATE(C0DED 1 IN COLUMN 21)
-
SfATUS
ATTENDING
IS HEISHE LITERACY
GRADE OR DEGRE€
( FOR SCHOOL
STUDENTS
,GRADE;
YES, IN
LITERATE
FOR UN IVERSITY
IRAN 1
1
STUDENTSYCOURSE
OF
STUDY; FOR
YES,
ABROAD 2 LLITERATE OTHERS, HIGHEST
CERTIFICATE OR
2
DEGREE RECEIVED)
NO
3
SCHOOL?
FIELD OF STUDY
( RELATING TO
GRADE ,COURSE OR
DEGREE RECORDED
XN COLUMN 22)
5
19
20
2i
23
22
rn
:.:.:.:.:. ...............
A:$<$ :ss::<<ss:
................................................
:.:.:.:z.
*
**
COLUMN 3 SHOULD BE LEFT BLANK FOR COLLECTIVE HOUSEHOLDS.
COLUMNS 16,17,18 19 SHOULD BE LEFT BLANK FOR UNSETTLED REGULAR HOUSEHOLDS.
NUMBER OF LITERATE MEMBERS
NUMBER OF ILLITERATE MEMBERS
IF HOUSEHOLD QUESTIONNAIRE
IS COMPOSED OF 2 OR MORE
SHEETS, MARK X IN THIS BOX
:.
-
ARTICLE 7 OF THE ACT ESTABLISHING THE STATISTICAL CENTRE OF IRAN
!3;HAS ANY-DEATH OR MARTYRDOM
EVENT OCCURRED IN THIS
HOUSEHOLD DURING THE LAST
12 MONTHS?
1
2
A l l inhabitants o f I r a n as well as I r a n i a n s u b j e c t s
residing abroad are bound t o give correct answers t o
questionnaires pertaining t o censuses and sample surveys
conducted by the s t a t i s t i c a l centre o f I r a n The i n f o r mation thus collected w i l l be t r e a t e d as c o n f i d e n t i a l
and must be used f o r no purposes other than s t a t i s t i c a l .
Such information shall by no means be used as evidence
f o r presentation t o administrative o r judiciary courts
or f o r the purpose o f taxation.
.
I
TO BE COMPLETED FOR PERSONS 6 YEARS OF AGE & OVER
ITO
NO
[7
KILN-DRIED BRICK &
STEELISTONE & STEEL
IF YES , FILL IN THE
TABLE BELOW
.
KILN-DRIED BRICK &
WOOD/STONE & WOOD
BE COMPLETED FOR PERSONS 9 YEARS OF AGE & OVER
MARITAL TO BE (
1,2 OR
ACTIVITY
STATUS DURING
THE LAST 7
DAYS
CEMENT BLOCKS (WITH
ROOF OF ANY KIND)
PLETED FOR WOMEN CODED
IN COLI 1 28
--
EMPLOYER 1
'EMPLOYED 1
UNEMPLOYED
(SEEK1NG WORK:
2
STUDENT
HOMEMAKER
INCOME
.RECIPIENT
OTHER
YES
37-PRINCIPAL CONSTRUCTION
MATERIALS USED IN THE
HOUSING UNIT:
REINFORCED CONCRETE
OR STEEL BEAM
SKELETON
rOTAL
OTAL
NUMBER
UMBER
OF
OF
:HILDREI
3
4
1 1;
3ORN
IONS , ENTER PRIVATE
HEIR NAMES )
5
6
ORKER
24
25
I
26
I
27
\LIVE
KILN-DRIED BRICK /
KILN-DRIED BRICK &
STONE
iAS SHE
;IVEN BIRTH TO
\ LIVE CHILD
IURING THE LAS
12 MONTHS ?
[ F YES ,
HILDREI iOW MANY ?
[ F NO ,
NOW
(ARK
IVING
II-''
ALL WOOD
SUN-DRIED BRICK &
WOOD
QUESTIONS 34 TO 43 SHOULD BE
COMPLETED ONLY FOR REGULAR
SETTLED HOUSEHOLDS.
SUN-DRIED BRICK &
MUD
NEVER
OTHER
5 MARRIED
4
I
28
29
30
MALE
FEMALE
31
32
34-TYPE OF HOUSING UNIT:
HUT,CAVERN
THE LIKE
KAPAR
(STRAW HUT)
CI2
COOKING
KEROSENE
40-TYPE OF TENANCY OF THE
HOUSING UNIT:
CI5
CI6
n
3
4
CI7
U8
og
SIGNATURE
:DITING REMARKS:
HOOD &
CHARCOAL
CI3
RENTED
OCCUPIED AGAINST
SERVICE (INCLUDING
STATE-OWNEDHOUSES)
$3-FACILITIES & UTILITIES :
FREE OF CHARGE
OTHER,SPECIFY
CODE 1
HOUSING
40-MAIN SOURCES OF WATER
USED BY THE HOUSEHOLD:
TYPE
OTHER
Oz
c l 4
WELL
RIVER
NUMBER OF EMPLOYED MEMBERS
2
OWNER OCCUPIED
(LAND & BUILDING)
u
u
1
n4
OTHER
36-HOW MANY ROOMS ARE THERE
IN THIS HOUSING UNIT'?
00
0
44-LINE NUMBER OF THE
RESPONDENT & DATE OF
INTERVIEW:
LINE NUMBER OF
THE RESPONDENT
IN COLUMN 1
IATE OF INTERVIEW DAY / MONTI
NAME & FAMILY NAME OF THE
CENSUS ENUMERATOR
u4
35-HOW MANY HOUSEHOLDS
ARE RISIDING IN THIS
HOUSING UNIT ?
GAS OIL
HEATING
C l 3
38-THE YEAR WHEN CONSTRUCTIOh
OF THE HOUSING UNIT WAS
COMPLETED:
REGULAR
TENT
CI1
CI2
42-TYPE OF FUEL USED FOR
COOKING & HEATING:
39-NUMBER OF ROOMS OCCUPIED
BY THE HOUSEHOLD:
PUBLIC
RESERVOIR
0 O6
5
o 7I
J
8
0
U l 0
2
iLECTR1:ITY
[ELE'HONE
'IPED
IATER
'IPED
ÌAS
\IR
ZONDIXONING
USED
BY THE
HOUSE4OT
HOLD 3
AVAILABLE
NOT
IN THE
USED
~ ~ ~ ~ 1
HOUSEBY
NTHE
G 2
HOLD 4
3
4
CREW LEADER
SIGNATURE
EDITOR
SIGNATURE