EVERYTHING WRITTEN ON
THIS FORM SHALL BE KEPT
CONFIDENTIAL
PREPARED AND PROMULGATED BY CENTRAL STEERING COMMITTEE ON
RURAL, AGRICULTURE AND AQUATIC PRODUCT RESERCH IN ACCORDANCE
WITH DECISION No 188/2005/QD-TTg DATE 26 JULY 2005 BY THE PRIME MINISTER
Form No: 1/DTH
Household No:
HOUSEHOLD QUESTIONNAIRE
Province, city: ..........................................................................
District, urban district, town: ...................................................
Commune, ward: ......................................................................
Village: .....................................................................................
Full name of household head:
Ethnic group: ...................
PART I: HOUSEHOLD, POPULATION, LABOUR
1. Population, labour capacity (regular residents only):
1.1. Number of people in household:
1.2. Number of people of working age:
1.3. Only write down those people of laboring age (exclude students, pupils) and people past laboring age who
are still working.
Professional
Activities in last 12 months
and technical Main form of employment:
qualification
Month,
Full name
Working sector
Working
year of Gender - No training
and
no
degree/
Agriculture
mode
=1
birth
(The first line is for
certificate
=1 - Forestry
No
Secondary
M=1
=
2
(only fill
household head)
- Primary,
F=2
- Aquaculture
= 3 - Selfemployment
in the
last two
numbers
of birth
year)
A
1
2
3
4
5
6
7
8
9
B
1
technical
worker
- Industry
- Construction
- Junior College =3 - Trading
- College
=4 - Transportation
- Other service
- University and
above
=5 activities
- Unemployed
2
3
=2
4
=1
= 4 employed
= 5 - Employee
=2
=6
=7
=8
=9
5
6
/
/
/
/
/
/
/
/
/
- Agriculture, Forestry, Aquaculture
- Industry, Construction
- Services
- Others
2. Main Source of Household Income in the last
12 months?
(Fill in suitable code in the box)
If the answer is code 1, move to question 3; code 2, 3, 4, move to question 4
- Agriculture
3. Was the main source of household income in
- Forestry
the last 12 months from agriculture, forestry,
Aquaculture
or aquaculture?
(Fill in suitable code in the box)
1
(code refers to
column 4)
=1
=2
=3
=4
=1
=2
=3
- Agriculture household =1
=2
- Forestry household
- Aquaculture household =3
=4
- Industry household
- Construction household =5
4. Main production sector of
the household:
(Fill in suitable code in the box)
- Trade household
- Transportation
household
- Other service activ
- Others
=6
=7
=8
=9
5. Was the household considered a poor hh in 2005 by their commune/ward? Yes =1 ; No
PART II: LAND AREA USED AND LEASED BY HOUSEHOLD (as of 1/7/2006)
Unit: m2
Land not in use by
household
Land in use by household
In which
Code
Land rented,
borrowed,
contracted by
household
2
Total
area
A
1. Annual crop land
In which: Paddy field
2. Perennial crop land
3. Forestry land
In which: Natural forest
4. Water surface for aquaculture
B
1
Land
bought by
household
Land has
Land
not used
leased out,
for the last
lent out
12 months
3
4
5
01
02
03
04
05
06
PART III: AREA FOR ANIMAL HUSBANDARY, PLANTATION AND FISHERIES
1. Area of main agriculture species
Plant
A
1. Summer-August crop rice 2005
2. Winter crop rice 2005*
3. Winter-Spring crop rice 2006
4. Tea
5. Coffee
6. Rubber
7. Cashew
8. Pepper
9. Coconut
10. Orange, mandarin
11. Mango
12. Longan
13. Litchi, ramputan
14. Grapefruit and pomelo
15.
16.
Total area of
Code
plantation** (m2)
B
01
02
03
04
05
06
07
08
09
10
11
12
13
14
1
In which:
Productive area
(m2)
2
x
x
x
Note: - *Summer-August crop rice includes August-Winter crop rice and the third crop rice 2005
- **Total area of plantation (column 2) refers to plantation area as of July 1, 2006.
2
Scattered trees
with products
( trees)
3
x
x
x
2. Animal husbandry (as of July 1, 2006)
Quantity
(unit)
Code
1. Buffalos
2. Cows
01
02
03
04
05
06
07
08
09
- Hybrid cow s
- Milk cows
- Dairy cows
In which
Code
3. Pigs (excluding suckling pigs)
3.1. Sows
3.2. Porkers
In which: Hybrid pigs
4. Chickens
In which: Industrial chickens
5. Ducks
6. Geese
7. Goats, sheep
8. Bees
9.
10.
11.
Quantity
(unit)
10
11
12
13
14
15
3. Aquaculture area in last 12 months (as of July 1, 2006)
In which
Code Unit
A
B
1. Fish culture area
2. Shrimp culture area
3. Other
4. Aqua Breeding area
5. Breeding constructed
tank, pond capacity
C
Total
Fresh Brackish Salt
water
water water
1=2+3+4
2
3
In total of
Intensive
I paddy
and Semifield
intensive
4
5
6
2
01
02
03
04
m
m2
m2
m2
x
x
05
m3
x
x
4. Cage and raft aquaculture in last 12 months (as of July 1, 2006)
Number of cages/rafts (unit)
Code
A
B
1. Fish
2. Shrimp
3. Other products
Capacity per cage/raft (m3)
Total
In which:
Fresh water
Total
In which:
Fresh water
1
2
3
4
01
02
03
PART IV: HOUSE, MAIN FACILITIES AND LIVING ENVIRONMENT OF HOUSEHOLD
1. House
1.1. Type of house: Solid=1; Semi-solid =2;
Wood frame with cottage roof=3; Temporary =4
2
.................................. m
2. Number of home appliances (unit): the availlable number of appliances as of July 1, 2006
1.2. Total area of the house:
Item
1. Motorbike
2. Colour TV
3. B&W TV
4. Video player
Quantity
Item
5. Radio, cassettes
6. Desk phone*
7. Mobile phone
Quantity
8. Refrigerator, fridge
Item
Quantity
9. Electric fans
10. Water heater tank
11. Computer
In which: Internet access
Note: *A desk phone is of a fixed telephone line subscription; excludes other sub-connecting phone.
3
3. Is electricity used by the household?
Yes=1; No=2
National electricity cable =1; Other source=2
3.1. If yes, what is its source?
- Tap - water
- Purchased water
(tank, jar, bottle,…)
- Rain water
- Drilled well water
4. Main source of Fresh water for
cooking and drinking?
(Fill appropriate code in the box )
=1
- Constructed well water
- Other well water
- River, lake, pond water
- Spring water
- Other sources
=2
=3
=4
=5
=6
=7
=8
=9
5. Is a purifying system or chemical used to treat cooking and drinking water? Yes=1; No=2
6. What is the main fuel used for cooking? Gas=1; Electricity=2; Coal=3; Wood=4; Others=5
7. What type of bathroom is being used? Constructed bathroom=1; Other kind=2; No bathroom=3
8. What type of latrine is being used? Household septic latrines=1; Pour-flush filtered latrines=2;
Eco-latrines=3; Ventilated improved pit latrines=4; Other latrines=5; No latrine=6
PART V: MAJOR EQUIPMENT AND MACHINERY OF THE HH (as of July 1, 2006)
Item
Quantity (unit)
Code
1. Heavy ploughing machines, tractor (more than 35 CV)
01
2. Medium-sized ploughing machines, tractors (from 12 CV to 35 CV)
02
3. Small ploughing machines, tractors (12 CV and less)
03
4. Vehicles (total)
04
In which: cargo and passenger vehicles
05
5. Forced
5.1. Electrical engines
06
07
5.2. Petrol, diesel engines
generator
6. Generators
08
7. Rice mowing machines with engines
09
8. Agriculture, forestry, aquaculture product dryers, ovens
10
9. Milling machines (xay xát, đánh bóng, phân loại...)
11
10. Wood-working power machines (power-saw, planer...)
12
11. Motorized Insecticide sprayers
13
12. Water pumps for agriculture, forestry, aquaculture production
14
13. Animal food processing machines (pulverizor, mixer, divider...)
15
14. Aquaculture food processing machines (pulverizor, mixer,...)
16
15. Motorized boats, ships (cargo and passenger transportation)
17
16. Non-motorized fishing boats
18
17. Motorized boats and ships for Aquaculture services
19
18. Motorized fishing boats
Fishing territory
Major catching method
(Tick
×
in
appropriate
cell)
(Tick × in appropriate cell)
Code Capacity
Ocean
Pulling Encircl Turnin Lift
(CV)
Inland
Fishing
Near
Offshore net ing net g net net
Other
shore
A
- Ship, boat 1
- Ship, boat 2
- Ship, boat 3
- Ship, boat 4
- Ship, boat 5
B
1
2
3
4
5
6
7
8
9
20
21
22
23
24
(Date) July ......., 2006
Household head
(Signature and full name)
Enumerator
(Signature and full name)
4
10