Annex 2
Form 01
№
of dwelling within
enumeration district
List of household members living in this
dwelling №
and their housing condition
№ of census № of instructors № of counting
division
point
point
1
2
3
№ of dwelling list of household
within counting
members living in
point
the dwelling №
4
5
6
8
7
REPUBLIC, oblast
17
Settlement
№ of quest. in the № of portfolio
census portfolio
9
10
Reserve
Institutional living quarters
(boarding house for old
people/ invalids,
house for orphans,
monastery etc)
Prospect, street, square, lane
homeless (es)
18
№ building
№ apartment
Name of the house owner
1. List of household members living in this dwelling
№ of household
member
Name and surname
1
2
19
Temporary
living
for
20
11
1
12
2
13
3
14
А
15
Б
16
В
persons
For residents who are temporarily absent
specify
Reason of absence
Duration of absence
(number of months or
otherwise indicate
“less then month»)
3
4
21
22
23
24
25
26
27
28
29
30
323
Annex 2
Form 01 (continued)
2. Household housing conditions
( temporal residents living in institutional organizations and homeless persons
do not reply to the questions 1-7)
1.Type of living quarters
1
31
Private house
2
32
Part of private house
3
33
Individual appartment
4
34
Communal appartment
5
35
Hostel
6
36
Hotel
7
8
Other
37
38
Rented housing
39
2. Number of occupied living
rooms
40
1
3. Space of private house,
part
of
private
house,
individual
or
communal
apartment (sq.m)
4. Do you or members of your
household possess
agricultural land plots
5. If yes, please indicate the
type of ownership
6. What is the total area of your
land plots
1
43
Part of room
41
total
42
living
yes
44
2
1
45
private property
2
46
rented
3
47
other
no
1
48
less 0,1 ha
4
51
from 1.1 to 5 ha
2
49
from 0,1 to 0,5 ha
5
52
from 5.1 to 10 ha
3
50
from 0,51 to 1 ha
6
53
above 10 ha
55
no
7. Do you lease your land plots
1
324
Living rooms
54
yes
2
Annex 2
Form 2С
CENSUS QUESTIONNAIRE
List of household
№ of dwelling
within counting members living in the
dwelling №
point
№ of census № of instructors № of counting
division
point
point
1
2
3
4
5
6
№ of
№ of questionnaire
household
within
№ of
member
portfolio
portfolio
8
7
Reserve
11 1
10
9
12
2
13
Name and Surname
3
1. Relations to the Head of the
Household
1 17 head of the
4
household
2 18 wife,
5
husband
3
daughter 6
son
19
21
22
mother 7
father
10. Education (for persons aged 6 and above)
1 53 Completed high education 6 58 basic secondary
23 mother in 10
law, father
20
26 other
relative
relations
in law
27 do not have
sister 8 24 grand mother, 11
relative ties
brother
grand father
№ of
28
daughter/ 9
grand daughter
mother,
25
son in law
son
(father)
2
54
3
Basic high education
7
55 Primary high education
4
Б
60do not have primary
education
1996 )
57
15
Uncompleted high education
(for those who graduated before
56
5
А
education
primary education
59
8
14
Completed secondary education 9
16
В
61
can`t write
Educational institution graduated, number of forms (courses), year of graduation
2. Sex
29
1
men
2
women
30
11. Have you graduated vocational school
(for persons aged 15 and above)
3. Temporarily
1
31
absent
2
residing
32
1
62
yes
2
63
no
4. Date of birth
day
month
33
study
year
34
number of complete years
12.Type of educational establishment where you
36
35
(for persons aged 6 and above)
1
5. Place of birth (indicate: Autonomous Republic of Crimea,
oblast, Kiev, Sevastopol, other country)
37
38
40
41
42 42
8. Citizenship
1
43
Ukraine 2
44
Without
45
of other country (indicate)
66
Secondary school
65
Vocational
2
school
67
Other
4
(courses)
5
68
9. Family status (for persons aged 15 and above)
1
71
Work for enterprise, organization, institution, farm
2
72
Work for private persons
3
73
Self-employed (own enterprise)
4
74
Work performed on the individual basis
5
75
Work at own agriculture farm
6
76
work without payment at family enterprise
7
77
Work at private subsidiary agriculture
8
78
Income from property
9
79
Pension
10
80
Scholarship
1
46
Single
5
50
Divorced
2
47
Married
6
51
Separated
3
48
Live with partner
11
81
Benefits (excluding unemployment allowances)
4
49
Widow/widower
12
82
Unemployment allowances
13
83
Other government social security
14
84
Dependant
52
Do not study
13. Sources of living
39
а) mother language (indicate)
б) If Ukrainian is not your mother language, please, indicate whether
you know Ukrainian fluently 1
yes 2
no
в) other language, which you know fluently (indicate)
High school 3
For persons aged below 7 who do not attend school, indicate whether
6 69 yes 7 70 no
he/she attends preschool establishment
6. Ethnic origin (indicate nationality or ethnic group)
7. Language
64
№ of wife
(husband)
15
Other source
Number of the
main source of
living
86
325
85
Annex 2
Form 2С (continued)
Temporary residents do not reply to the questions 14-19
14. Full name of organization, enterprise, own business, where you performed
your main job, type of activity (indicate)
87
88
15. Your work at the main job
(indicate your occupation, position or work )
16. Whereabouts of your place of work
on the territory of my residence
89
on other territory (specify)
90
(Autonomous Republic of Crimea, oblast, Kiev, Sevastopol, other country-specify)
17. Status in employment
91
1
2
92
employee
93
3
member of productive
cooperative
employer
4
94
5
95
unpaid family worker
self-employed
18. Do you live in this settlement since birthday?
1
96
297
yes
no
а) if no , indicate the year since which you have been permanently living in this settlement
moving to another place falls on period from 5.12.2000 to 5.12.2001
3
б) place of your previous residence (specify)
98
99
100
(Autonomous Republic of Crimea, oblast, Kiev, Sevastopol, other country-specify)
в) type of the settlement from which you arrived
г) are you:
4
101
urban
5
103
refugee
6
7
102
rural
104
deportee
For females (aged 15 and above)
19. Have you given birth to a child(ren)?
1
105
yes
2
106
no
If yes, specify:
а) number of children you gave birth to
107
б) number of living children
108
326
Census (62).max
Census (62).max
Census (62).max
Census (62).max