Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697797179434.pdf (Dominica)
39751 IMPORTANT!!!

PARISH NO ED NUMBER HOUSEHOLD NO INDIVIDUAL QUESTIONNAIRE Transfer codes from front page of housing questionnaire INTERVIEWER: Whenever a dotted line (...) appears in a question, call the name of the person to whom the information relates, if it is not the respondent himself/herself.

Else say "You"'/"Your".

X the appropriate box.

Please do not write over the responses: SECTION 1: CHARACTERISTICS FOR ALL PERSONS 1.7A Do .... have a working mobile phone ?

.
.

1 Yes 2 No (skip to Q1.8) 3 Not Stated 1.1.

Please fill in this person's assigned number from household roster 1.2 What is .....'s relationship to the head of household?

1 Head 6 Grandchild 2 Spouse/partner 7 Parent/parent-in-law 3 Child 4 Son/daughter-in-law 5 Step son / daughter 8 Other relative 9 Non-relative 1.3.

INTERVIEWER: Fill the appropriate oval.

FOR PERSONS NOT SEEN ASK: Is.........male or female?

1 Male 2 Female 1.4 What is.......'s date of birth (DD/MM/YYYY)?
/ / If not known, ask: How old was..........on his/her last birthday?

If age is not stated please estimate age if you see the person.
Otherwise ask the respondent to estimate the person's age use 97 for age over 96 1.7B How much did ..... spend on cellular telephone(s) (pre-paid and/or post-paid) in the last month (exclude balances from previous bills, include monthly package cost and additional cost for text messaging, caller ID, call waiting, etc) $ , Note that for post paid the amount required is the amount billed 1.8.

Where did you USE the internet in the last 12 months .......?
X all that apply 1 Home 2 Work 3 School 4 Internet Cafe 5 Cell Phone 6 Family Friend 7 Other 8 No Access 9 Did not use SECTION 2: MIGRATION FOR ALL PERSONS 2.1 Where was.......mother's place of usual residence when........was born?

1 Dominica 2 Abroad (Another Country) Go to Q2.3 Estimate 2.2 In which district/parish was .....'s.

mother living?

1.5 To what ethnic, racial or national group do you think..........belongs?
1 African Descent/Negro/Black 6 Syrian/Lebanese 2 Indigenous People (Amerindian/Carib) 7 White/Caucasian 3 East Indian 4 Chinese/Asian 5 Portuguese 8 Mixed 10 Don't know/Not Stated 9 Other (please specify.............................) (All go to Q3.0) 2.3 In which country was.........mother living?

1.6 What is..........'s religion/denomination?


1 Anglican 2 Baptist 3 Bahai 4 Brethren 11 Muslim 20 Wesleyan Holiness 12 Pentecostal 13 Presbyterian 14 Rastafarian 5 Church of God 15 Roman Catholic 6 Evangelical 16 Salvation Army 7 Hindu 17 Seventh Day Adventist 8 Jehovah Witnesses 18 None 9 Methodist 10 Moravian 19 Not Stated 21 Other (please specify............................. 2.4 Why did ........return/come to Dominica?
1 Regard it as home/Homesick 5 To start a business 2 Family is here 6 The Weather 3 Deported 4 Retired 10 Other 7 To obtain employment 8 Health Reasons 9 Return from Study SECTION 3: HEALTH FOR ALL PERSONS 3.0 Does any member of ....... household frequently engage in any of the following (X all that apply) 1 Drinking Alcohol 2 Smoking of Cigarettes 3 Smoking/Ingestion of banned Substances 7 Abuse of Prescription Drugs 8 Other 4 Sexual abuse 5 Physical abuse of another member of household 6 Physical abuse of children 9 Don t Know 10 None 1 0 0 0 0 0 0 7 1 0 0 0 0 0 0 7 Page 1 SAMPLE 39751 SECTION 3: HEALTH FOR ALL PERSONS SECTION 3: HEALTH con't FOR ALL PERSONS 3.1 Did...... have to be confined to bed during the past thirty (30) days due to any illness or injury?
For example, cold, diarrhea, fever, headache, stomach ache, dizziness, severe pains or other illness/injury due to accident?

1 Yes 2 No If No, go to Q3.3 3.2 What type of illness/injury was this?

list only the major illness/injury as clearly as possible 3.15 How long did ........ have to wait at this place before being attended to?

Minutes 3.16 How satisfied were/was ....... with the attention/treatment received?
1 Very satisfied, Go to Q3.18 3 Dissatisfied 2 Satisfied, Go to Q3.18 4 Very dissatisfied 3.3 During the past 30 days, did ...... suffer from cold, diarrhea, fever, headache, stomach ache, dizziness, severe pains or other illness/injury due to accident?

1 Yes 2 No If No, go to Q3.5 3.17 Why were/was............ not satisfied?
(Select all that apply) 1 Drugs not available 3 Attitude of Staff 2 Drugs not affordable 4 Long waiting time 6 No Doctor/Trained staff available 3.4 What type of illness/injury was this?

5 Equipment not available or operational 7 To many revisits list only the major illness/injury as clearly as possible 3.5 Does .... suffer from any of the following diseases, Diabetes, High Blood Pressure, Heart Condition, Cancer, HIV, asthma?

1 Yes 2 No 3.6 If yes, which of these?


If yes to either Q3.1 or Q3.3 and No to Q3.5 go to Q3.7 if No to Q3.1, Q3.3 and Q3.5 go to Q3.28 Otherwise, answer Q3.6 and Continue 1 Diabetes 2 High Blood Pressure 3 Heart Condition 4 Cancer 5 HIV/AIDS 6 Asthma 7 Other 3.7 Did .......'s illness/injury begin within or before the last thirty (30) days?

1 Within 2 Before 3.18 How much did ......... have to pay at public health facilities for all visits made during the past thirty (30) days?
Do not include the cost of drugs or any cost paid by your insurance.

$ , EC 3.19 How much did ......... have to pay at private/public health facilities for all visits made during the past thirty (30) days?

Do not include the cost of drugs or any cost paid by your insurance.

$ , EC 3.20 Did ...... spend the night in a public/private hospital or any other public establishment during the past thirty (30) days?
1 Yes 2 No If no to Q3.23 3.8 For how many days during the past thirty (30) days was\were ..... unable to carry on his/her usual activities because of illness/injury?

3.21 How many nights during the past thirty (30) days did ...... spend in the public/private hospital?

1.

How many of these were days of work without pay?

2.
2.

Days Days Nights 3.9 Did ...... visit a doctor, nurse, pharmacist, healer, spiritual healer, midwife or other health practitioner during the past thirty (30) days due to illness/injury?

3.22 How much did ...... have to pay or have paid altogether for his/her stay in a public/Private hospital during the past (30) days?

Do not include the cost of drugs or any cost paid by your insurance.

1 Yes (Go to Q 3.11) 2 No 3.10 If no, why not?


$ , EC 1 No Need 2 Too expensive 3 Too far 3.23 Did ...... buy medicines during the past thirty (30) days?

4 Un treatable 5 Other After Q 3.10 go to Q3.23 3.11 How many visits did ...... make in the past thirty (30) days to health practitioners?

Visits 3.12 Where was ..... first visit made?


1 Princess Margaret Hospital 2 Portsmouth Hospital 3 Health Center 6 Private Doctor/Dentist 7 Traditional Healer 8 Hospital Abroad 4 Private doctor/ dentist abroad 9 Pharmacy / Chemist 1 Yes 2 No If no to Q3.28 3.24 Did ...... obtain medicines at a public facility or pharmacy?

1 Yes 2 No If no, go to Q3.26 3.25 How much would ....... have spent if he/she were to purchase the medicines obtained from a public facility at a private facility?
$ , EC 3.26 Did ...... obtain medicines at a private facility?

1 Yes 2 No 3.27 How much has ....... spent for medicines at private/public sources 10 Other (include visits by nurse/doctor to home) in the past (30) days?

3.13 Why did ...... go there first?

Private (in EC Dollars) Public (in EC Dollars) $ , , 3.14 Who attended to ......... first visit?

3.28 Is ...... covered by Private Health Insurance, Employee Medical 1 Nurse, health care worker 2 Pharmacist 3 Healer Plan?
1 Yes 2 No 4 Doctor 5 Midwife 6 Other 1 0 0 0 0 0 0 7 Page 2 SAMPLE 39751 SECTION 4: EDUCATION FOR ALL PERSONS 4.14 Does.......have all textbooks required for his/her use at school?

4.1 Can ...... read and write?

1 Yes 2 No 1 Yes, has books for exclusive use (Go to Q4.18) 2 Yes, but shares with other family members 4.2 Is/are ..... attending school/classes?

1 Yes 2 No If no to Q4.19 3 Has only some books 4.3 Is it?
1 Full-time 2 Part-time 3 Not Stated 4 Has none (if none, go to Q4.17) 4.4 What is the current grade ...... are/is attending at present?
10 G1/Infants2 20 Form1 00 none 11 Grade 2 21 Form2 01 Nursery 12 Grade 3 22 Form3 02 Pre-school 03 GK/Infants1 13 Grade 4 23 Form4 04 Special Education 14 Grage 5 24 Form5 15 Grade 6 32 CommCollege - A'Level 33 CommCollege - Tech 34 CommCollege - Nursing 35 CommCollege - Teachers 36 University-UWI 37 University-USA 30 Educational Institute - Diploma 38 University-Other 31 College - Associate Degree 39 Other 40 Don't know 4.5 Does ........ attend private school/classes?
1 Yes 2 No 4.15 Were any of..........'s books provided by the school at no cost?

1 Yes 2 No 4.16 Were some of these books acquired by.........in any of the following ways?

(Select all that apply) 1 Borrowed for use during year 6 Received from NGO 2 Received from relatives or friends 7 Government Book Loan 3 Purchased New 5 Bought some/got some on loan or free 4 Purchased second hand 8 Other 4.6a Does ...... live at home while attending school/classes?

INTERVIEWER: for those answering 1 in Q.


4.14 go to Q.4.18 1 Yes 2 No 4.6b Are/is ....... enrolled in a distant education programme?

1 Books not available 4 Books were lost or destroyed 1 Yes 2 No (If yes, go to Q4.21) 2 Could not afford 5 To be purchased For Part time and distant education persons, you should proceed to Q4.21 4.7 During the last five days of school how many days did ...... actually go to school/classes?
3 Books available in school library 6 Other (Specify) 4.17 What are the reasons for.......not having required textbooks?

Days (If 5 days go to Q4.9) 4.18 Has.......or.......'s parents ever made use of a book loan facility?

4.8 Why did ........ not go to school during all of the last five school days?

1 Illness 6 Not worth going All go to Q.


4.25 1 Yes 2 No 2 Financial Problems 7 School closed/holidays 3 Transportation Problems 8 Truant/Delinquent (no reason) 4 Working 5 Home duties 11 Apprenticeship 12 Fear of Gangs 15 Other (Specify 9 Pregnant/young mother 10 Baby sitting 14 Menstrual Problems 4.9 How far away is ...... school from here (in minutes based on his/her usual/normal means of getting there)?

Minutes 4.10 How does ...... normally get to school?
1 Walking 2 Cycling 3 Taxi 4 Bus/Mini Bus 5 Private transport 6 Other (Specify) 4.11 Is there a school feeding programme at.............'s school?

1 Yes 2 No (if no, go to Q4.14) FOR PERSONS NOT ATTENDING SCHOOL AT PRESENT 4.19 For persons under sixteen (16) years of age, what is the MAIN reason........ did not attend school?
1 Too young 2 Financial Problems 3 Transportation Problems 4 Working 5 Illness 6 Physically/mentally challenged 7 No school available 8 No space in school 16 Not applicable (if person > 15 years) 9 Pregnant/young mother 10 Baby sitting 11 Apprenticeship 12 Not worth going to school 13 Expelled 14 Suspended 15 Other (Specify 4.20 Has........ ever attended school?

1 Yes 2 No (If no, go to Q4.24) 4.21 What age did ...... start formal education?

4.22 What age did ...... leave formal education?


4.12 Do you pay for the school meal service?

4.23 What is the highest grade ...... completed?

1 Yes 2 No 4.13 Does.......receive meals or snack from this service?
1 Yes 2 No 10 G1/Infants2 20 Form1 00 none 11 G2/Class1/Std1 21 Form2 01 Nursery 02 Pre-school 12 G3/Class2/Std2 22 Form3 03 GK/Infants1/Stg1 13 G4/Class3/Std3 23 Form4 04 Special Education 14 G5/Class4/Std4 24 Form5 32 CommCollege - A'Level 33 CommCollege - Tech 34 CommCollege - Nursing 35 CommCollege - Teachers 36 University-UWI 15 G6/Class5/Std5 25 Upper6 37 University-USA 16 Sen1/MPC/Class6 26 Lower6 38 University-Other 17 Sen2/MPC/Class6 30 Educational Institute - Diploma 18 Sen3/MPC/Class6 31 College - Associate Degree 39 Other 40 Don't know 1 0 0 0 0 0 0 7 Page 3 SAMPLE 39751 4.24 What is the highest examination ever passed?
1 None 2 School leaving Certificate 3 Standard Seven - School Leaving Certificate 4 JSP(Junior Secondary Programme) 5 CXC Basic 6 GCE "O"/CXC Gen Prof (1 or 2 subjects) Grade I, II, III 7 GCE "O"/CXC Gen Prof (3 or 4 subjects) Grade I, II, III 8 GCE "O"/CXC Gen Prof (5 and over subjects) Grade I, II, III 9 GCE "A"/CAPE/HSC 1 or 2 10 GCE "A"/CAPE/HSC 3 and over 11 Diploma or Equivalent Certificate 12 Associate Degree 13 Undergraduate Degree 14 Postgraduate Degree 15 Professional Qualifications - Computer 17 Professional Qualifications - Other 18 Other, Specify_______________________ 4.25 Did ...... have any vocational or technical training?
1 Vocational 3 Both SECTION 5: EMPLOYMENT FOR PERSONS 15 YEARS AND OVER 5.9 What is the main activity at the place of ....... 's main job?

Describe as clearly as possible activities of the business where you work.

5.10 What is..... status in the main job?

1 Paid Employee - Government 5 Self employed with employees 2 Paid Employee - Statutory 6 Unpaid family worker 4 Self employed without employees (If 1,2 or 3 go to Q5.12) 5.11 Please provide the following information for the last twelve months?
16 Professional Qualifications - Accounting 3 Paid Employee - private 7 Other 2 Technical 4 None If under 15, go to Section 7 1.

Location 1 Fixed 2 Moved from place to place SECTION 5: EMPLOYMENT FOR PERSONS 15 YEARS AND OVER 2.

Average value of sales/service 5.1a Did you work at all in the past twelve months (includes partime and full time)?

1 Yes 2 No (If No, go to Q5.3) 3.

Product/service provided 5.1b How many months did you/he/she work in the past 12 months?

11 10 5 7 6 9 2 1 4 3 8 0 12 4.


Total Capital Invested $ $ , , EC EC 5.1c Did ...... do any type of work in the last 7 days?

1 Yes 2 No (If Yes go to Q5.5) If 12 Go to Q5.5 5.12 What has been the major problem preventing you from earning a higher income in the past twelve months?

5.2 Was ...... absent from work in the last 7 days?

For all persons who are employed go to Q6.1 1 Yes 2 No (If Yes go to Q5.5) 5.3 Has ..... been looking for work and ready for work in the last month?
1 Yes 2 No (If yes, go to Q5.13) 5.4 What was the main reason ...... was not working in the last 7 days?

1 No work available 6 Infirmity/Disabled 2 Seasonal inactivity 7 Did not want to work 3 Student 8 Maternity Leave 4 Household/family duties 9 Other 5 Retired (All go to Q5.13) 5.5 How many years have .... been in this job?

Years 5.6 How many hours did/does ..... normally work in a week?

00 for under 6 mths (if greater than 35 hours, go to Q5.8) 5.7 What is the reason for working less than 35 hours?
1 Own illness/injury 2 Holiday/vacation 6 Job ended in reference week 7 Firm not getting enough work 3 Personal/family responsibilities 8 Could not find more work 4 In school/training 5 Strike/lock out 11 Other 9 Part Time Work 10 Pregnancy FOR ALL PERSONS WHO DID NOT WORK OR DO ANYTHING TO EARN AN INCOME LAST WEEK 5.13 When last did …… work?
1 Never Worked (Go to Q 5.15) 4 3 but less than 6 months 2 Less than one month 5 6 but less than 12 months 3 1 but less than 3 months 6 1 year and more 5.14 What was the main reason why …… left last job?

1 New Job 2 Fired 3 Illness/Injury 4 Retired 7 Did not want to work 8 No more work available 9 Wages too low 10 Seasonal job 5 To return to school 11 Home Duties 6 Retrenched/laid off 12 Sexual Harassment 14 Other (Specify) 13 Pregnancy 5.15 Did …… look for work or do anything to earn income last week?
1 Yes 2 No (If yes, go to Q5.17) 5.16 Why did …… not seek work or do anything to earn income last week?

1 At school 7 Awaiting results or applications 2 Housekeeping 8 Knew of no vacancy 3 Retired 4 Disabled 9 Discouraged 10 Caring for someone 5 Temporary illness 11 Pregnancy 5.8 What is your occupation, that is what activities do you do in your work?

e.g.
e.g.

sales manager or sales clerk, mason etc 6 Did not want work 12 Other (specify) 1 0 0 0 0 0 0 7 (All, go to Q5.18) Page 4 SAMPLE 39751 5.17 What kind of work are you looking for?

INTERVIEWER: What is required is a description of the work you are looking for e.g.

sales manager or sales clerk, mason etc 6.7 How many live births did you/she have in the last 12 months?
1 None (If no, go to Q7.1) 2 One 3 Two separate births 4 Twins 5 Three or more 5.18 What would have prevented …… from doing a job if one were available during the last month?

1 At school 7 Have to stay home with children 2 Housekeeping 8 Pregnancy 3 Retired 4 Disabled 10 Caring for someone 11 Other (specify) 5 Temporary illness 12 Don't KNow 6 Did not want work 13 Nothing SECTION 6: MARITAL STATUS, UNION STATUS AND FERTILITY FOR PERSONS 15 YEARS AND OVER 6.1 What is your/....'s present union status?
1 Legally married 2 Common Law union 3 Visiting partner 4 Married but not in union 6 Widowed and not in union 7 Divorced and not in union 8 Not in a union 9 Don't know/Not stated 5 Legally separated and not in a union 6.2 Is/Are ...... currently pregnant?

1 Yes 2 No 3 Not Stated 4 Not Applicable (for Males) 5 Don't Know if yes, skip to Q6.3 6.2bAre you currently practicing a form of birth control?

1 Yes 2 No 6.2c If yes, what is the MAIN form you use?

6.8 Of these, have any of the babies died?


1 Yes 2 No (If no, go to Q7.1) 6.9 How many have died?

Within the first 30 days of life After 30 days but before one year SECTION 7 CRIME 7.1 In the last 12 months have you/he/she.............been a victim of crime?

1 Yes 2 No 3 Not Stated If No, go to Section 8 for all spenders Otherwise end the interview 7.2 A.

Describe the nature of the main crime (inclusive of domestic violence)?
Spenders, continue to Section 8 End of Interview for all non- spenders Not applicable Leave Blank Not Known 9's ending in 8 Amount too large 9's ending in 7 Not Stated Try harder, if not use all 9's 1 Pill 2 IUD 3 Abstinence 4 Injectable 5 Diaphragm foam/jelly 6 Male Condoms 7 Female Condoms 8 Female sterilization 9 Male sterilization 10 Norplant 11 Rhythm 12 Withdrawal 14 Other 13 Other Traditional All males go to Q7.1 FOR FEMALES 15 TO 49 YEARS 6.3 Is/Are ...... attending/visiting a public health clinic/private doctor?
1 Yes 2 No 6.4 How many live births has ....... ever had?

(if Zero, enter 00 and skip to Q7.1) 6.5 How many died?

Before first birthday After first birthday 6.6 How old were you/was she when you/she had the first live born child?

1 0 0 0 0 0 0 7 Page 5 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.

Did ....... purchase or receive as gifts any of the following items in the past 3 months?
PURCHASED (homemade) GIFTS DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) Material for men and boy's garments Suiting Material Tweed Khaki Material for school Trousers 0311101 0311102 0311103 0311104 Tailoring for Suit 0311105 Tailoring for Trousers 0311106 Material for women and children garments Crepe back Satin Satin Chiffon Linen Madras Poplin Flowered Cotton Silk Polyester Material for school overall Material for school shirts Suiting material Over lace 0311201 0311202 0311203 0311204 0311205 0311206 0311207 0311208 0311209 0311310 0311311 0311312 0311313 0311314 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 6 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Seamstress fees for suit Seamstress fees for uniform Seamstress fees for formal wear 0311315 0311316 0311317 Men's Garments -Outer wear Complete Suits - 2 piece 0312101 Jackets Sweaters 0312102 0312103 Waistcoats/pullovers 0312104 Long Trousers/ pants for dress and office Long Trousers/ pants casual wear Long Jeans pants Short pants (casual) 0312105 0312106 0312107 0312108 Short pants (Jeans) 0312109 Short pants(house wear) Shirts - long sleeves (dress) Shirts (casual, working) Jerseys (dress, working) 0312110 0312111 0312112 0312113 Sports wear /vests 0312114 Polo Shirts 0312115 T- Shirts 0312116 Track suits /Jogging suits 0312117 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 7 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or recieve as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Pyjamas 0312118 Bath robes /housecoats 0312119 Costumes 0312120 Overcoat/ raincoat 0312121 Work overalls 0312122 Men's outerwear not specified by type Men's underwear and Hosiery Vests 0312199 0312124 Boxer shorts 0312125 Underwear /underpants Socks All other men's outer wear Other articles of Men's clothing Ties & Scarves Hats and caps Belts Beachwear Braces 0312126 0312127 0312199 0313101 0313102 0313103 0313104 0313105 Handkerchiefs 0313106 Sewing thread, buttons, zips, buckles Helmets 0313107 0313008 Other men's clothing 0313199 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 8 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Boy's outer wear Complete Suits -2/3 piece Jackets Sweaters 0312201 0312202 0312203 Waistcoats / pullovers 0312204 Long Trousers /pants (dress) Long trousers / pants (casual wear) 0312205 0312206 Long Jeans pants 0312207 Short pants (casual) Short pants (Jeans) Short pants (house wear) Shirts -dress(Long sleeves) Shirts (casual) Jerseys (dress) Sports wear/ vests Polo Shirts T- Shirts Track suits/ Jogging suits Pyjamas Bath robes /housecoats Costumes 0312208 0312209 0312210 0312211 0312212 0312213 0312214 0312215 0312216 0312217 0312218 0312219 0312220 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 9 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Overcoat/ raincoat 0312221 Boy's outer wear not specified by type Boy's underwear and Hosiery Vests 0312299 0312224 Boxer shorts 0312225 Underwear / underpants 0312226 Socks 0312227 All other boy's outer wear 0312299 Boy's school garments Long Pants (school) 0312228 Short Pants (school) 0312229 Shirt (school) 0312230 Sports uniform 0312231 Other articles of Boy's clothing Ties & Scarves Hats and caps Belts Beachwear Other boy's clothing 0313201 0313202 0313203 0313204 0313299 Women's outer wear Skirt Suits (2 or 3 piece) 0312301 Pants suits 0312302 Dresses (evening formal) Dresses (office) 0312303 0312304 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 10 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Dresses (casual) 0312305 Shirts /blouses (formal) 0312306 Shirts / blouses (casual) 0312307 Skirts (long) 0312308 Skirts (short) 0312309 Slacks / trousers 0312310 Jeans (Long) 0312311 Jeans (short) 0312312 T- shirts Jerseys with sleeves 0312313 0312314 Jerseys without sleeves 0312315 Polo -shirts Overalls Track suits / Jogging suits Sports clothes (netball) 0312316 0312317 0312318 0312319 Sweaters / Jumpers 0312320 House clothes 0312321 Sleep wear 0312322 Robes/ Housecoats 0312323 Raincoats / overcoats 0312324 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 11 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS All other women's outer wear Women's Underwear Slips- half or full Bras Vests Panties 0312399 0312325 0312326 0312327 0312328 Tights / Panty hose 0312329 Girdles Socks Stockings Other Women's Clothing and Clothing Accessories Hats Bathing suits / Beachwear Scarves / belts Bags Purses Watches Necklaces and earrings (Gold, silver, precious stones) Necklaces and earrings (cosmetics) 0312330 0312331 0312332 0313301 0313302 0313303 0313304 0313305 0313306 0313307 0313308 Girls Outer wear Dresses (formal/ evening) 0312401 Shirts/ blouses (casual) 0312402 T- shirts 0312403 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 12 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Skirts (casual) 0312404 Slacks / trousers 0312405 Jeans pants (long/short) 0312406 Jeans skirts 0312407 Pants suits (casual) 0312408 Jerseys House clothes Sleep wear / pajamas Raincoats 0312409 0312410 0312411 0312412 Other girls outer wear not specified by type 0312499 Girl's underwear and hosiery Bras Panties Vests Tights Socks/ stockings 0312424 0312425 0312426 0312427 0312428 Girl's school garments School Overall 0312430 School blouses/ shirts 0412431 School Skirts 0412432 Sports uniform 0412433 Other girl's clothing Hats 0313401 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 13 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Bathing suits 0312402 Infants (under 1 year) Clothing and clothing accessories Dresses/ Suits 0313501 Play suits 0313502 Baby shirts /vests 0313503 Diapers 0313504 Socks/ booties 0313505 Hats /bonnets 0313506 Other infant clothing not specified by type Dry- cleaning, laundering and dying of garments Men and boy's clothing Women, girls and infants clothing Repairs and alterations Men and boys clothing Women and girls clothing Infants clothing Hire of garments Men and boys garments (Jackets, suits) Women and girls garments (Wedding out fits, evening gowns) Men and Boy's shoes (16yrs.
and over) Shoes - dress (man-made) Shoes - dress (Leather) 0313599 0314101 0314102 0314201 0314202 0314203 0314301 0314302 0321101 0321102 Shoes - casual 0321103 Sandals Sneakers /sports shoes/ gym shoes 0321104 0321105 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 14 SAMPLE SECTION 8: CLOTHING AND FOOT-WEAR CONSUMED DURING PAST 3 MONTHS 39751 8.
Did ....... purchase or receive as gifts any of the following items in the past 3 months?
DESCRIPTION CODE HAVE BOUGHT QTY BOUGHT TOTAL COST($) QTY recieved TOTAL COST($) PURCHASED (homemade) GIFTS Boots -work 0321106 Boots-casual 0321107 Slippers -house 0321108 Women and girls (16 years and over) Shoes -dress (man - made) 0321201 Shoes -dress (Leather) 0321202 Shoes -casual 0321203 Sandals 0321204 Sneakers/ sports shoes /gym shoes Boots 0321205 0321206 Slippers- fashion 0321207 Slippers- house 0321208 Infants and children (up to 16 years) Shoes -school Shoes -dress Sandals Sneakers / Sports shoes 0321301 0321302 0321303 0321304 Shoes -fashion 0321305 Slippers -house Shoe Repair Men and boys shoe repair Women and girls shoe repair 0321306 0322101 0322201 Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home Yes Home , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 15 SAMPLE 39751 SECTION 9 - OTHER EXPENSES (Always indicate value, Include Quantity where requested) 9.
Did ....... spend money on any of the following in the past 3 months?
Expenditure During Last 3 Months MEDICAL EXPENSES Doctors Fees (Number of visits) Dentist Fees (Number of visits) Child Delivery Fees Optician Fees Private hospital care (number of nights) Lab Tests and X-rays (number of lab test) Drugs for Hypertension Drugs for Cancer Drugs for Diabetes Drugs for Cold/Flu Other Drugs and Prescriptions, Medical supplies Spectacles, hearing aids, dentures, etc Health and Accident Insurance Other Medical Expenses EDUCATIONAL EXPENSES Tuition - For pre-school/Day Care Tuition - Correspondence Courses (all levels) Lessons for Children Primary/Secondary Lessons/Night Classes for Adults Tuition - Primary, Secondary School Tuition - Tertiary, University and Other Boarding and lodging School and technical books Exam fees CODE (Y/N) QUANTITY NO.
AMOUNT ($) SPENT 3 MONTHS 0621101 0622101 0621106 0621104 0630108 0623101 0611102 0611103 0611104 0611112 0611199 0613101 1253001 0623199 1010101 1040202 1050101 1050102 1040101 1040101 1120101 0951101 1040203 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No , , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 16 SAMPLE 39751 SECTION 9 - OTHER EXPENSES (Always indicate value, Include Quantity where requested) 9.
Did ....... spend money on any of the following in the past 3 months?

Expenditure During Last 3 Months CODE (Y/N) QUANTITY NO.
AMOUNT ($) SPENT 3 MONTHS EDUCATIONAL EXPENSES (Cont'd) Computer software and accessories 0913105 School Transportation fees (No of Trips) School Meals (No of Meals) Other ENTERTAINMENT EXPENSES Carnival Cinemas/video/DVD rentals/video clubs Concerts, plays, fetes and other admissions Spectator sports, football, cricket Night clubs, dances, parties Participant sports Dues, subscriptions and memberships Lottery games Newspapers Toys for Children Books,magazines (non-technical and not for school) Other Entertainment, Hobby Specify......................................................... 0737101 0119423 1050101 0942105 0914101 0942101 0941102 0942104 0942198 0942105 1270104 0952101 0931100 0952102 0942199 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No TRANSPORTATION BY AIR (for Quantity indicate number of visits) Yes Caribbean - Dominica - Antigua (No of Trips) Caribbean - Dominica to St. Maarteen (No of Trips) 0733101 0733102 Caribbean - Dominica to Guadeloupe/Martinique (No of Trips) 0733103 Caribbean - Other (No of Trips) 0733104 USA - New York, Miami, etc.. (No of Trips) England - London, etc (No of Trips) Other Foreign Travel by Air (No of Trips) 0733104 0733105 0733106 No Yes No Yes No Yes No Yes No Yes No Yes No , , , , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 17 SAMPLE SECTION 9 - OTHER EXPENSES 39751 9.
Did ....... spend money on any of the following in the past 3 months?

Expenditure During Last 3 Months CODE (Y/N) QUANTITY NO.
AMOUNT ($) SPENT 3 MONTHS TRANSPORTATION BY BOAT (for Quantity indicate number of trips) Inter-Island Travel Caribbean - Guardeloupe, Martinique (No of Trips) Other, B'dos, St Lucia, Trinidad and Tobago (No of Trips) PERSONAL AND OTHER EXPENSES Taxi Transportation Bus Transportation Weddings Legal and accounting expenses (non-business) Funerals Local accommodation expenses Barbershop Hairdresser Beauty Salon (manicures, pedicures, facials etc..) Laundry/Dry cleaners Photo studios Driving Lessons Other personal services 0734101 0734102 0732400 0732100 1270103 1270101 1270102 1120104 1211201 1211101 1211102 0562205 0942106 0724301 1211300 Other travelling expenses 0738102 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 18 SAMPLE SECTION 10 - OTHER DISBURSEMENTS 39751 10.
Did ....... spend money on any of the following last month?

Expenditure During Last Month CODE (Y/N) AMOUNT ($) Some of the more common expenditures are in bold NON-CONSUMPTION EXPENDITURES Income Taxes 2010001 Other taxes, duties, fees and other compulsory charges e.g.

Customs duties, departure tax, stamp duty etc.
2010002 Life insurance premium Annuities Interest on consumer loans Credit Card Payments Hire-purchase installments Gifts (Cash and financial) Allowances to children Alimony/Child maintenance Remittance sent to persons abroad Donations and charities Subscriptions and contributions to trade unions and other organizations Loans given out Social Security Contributions (from pay slip) Other Non Consumption Expenditure 1251001 2020001 2020002 2020003 2020004 2030001 2040001 2040002 2030002 2040003 2050001 2060001 1255102 2060099 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No , , , , , , , , , , , , , , , , DISBURSEMENTS OTHER THAN CONSUMPTION EXPENDITURES LAST TWELVE MONTHS Sou Sou Credit Union Shares Bank Deposits Treasury Bills / Government Bonds Stocks and shares in local companies Stocks and shares in foreign companies Investment in real estate (Land) Other Disbursements 2110001 2110002 2110003 2120001 2120002 2120003 2130001 2130099 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No , , , , , , , , 1 0 0 0 0 0 0 7 Page 19 SAMPLE SECTION 11 - INCOME 39751 Not applicable Leave Blank Not Known 9's ending in 8 Amount too large 9's ending in 7 Not Stated Try harder, if not use all 9's 11.
Did ....... receive money from any of the following sources?

CODE PERIOD 1 Daily 2 Weekly 3 Fortnightly 4 Monthly 5 Quarterly 6 Semi-Annually 7 Annually INCOME SOURCES - EMPLOYMENT INCOME CODE PERIOD AMOUNT ($) 1A.

What was...'s gross pay/income during the last pay period, from MAIN job, that is, before income tax or other deductions?

(PRESENT FLASH CARD) Income Group 1B.

How much did you receive in wages and salary LAST PAY PERIOD FROM MAIN JOB (GROSS PAY) .
Include Overtime, tips and bonuses, income taxes and Social Security 2231001 2.

Do you get this amount regularly?

1 Yes 2 No 3.

How much did you receive in wages and salary LAST PAY PERIOD FROM OTHER JOB (GROSS PAY).

Include Overtime, tips and bonuses, income taxes and Social Security 2231002 4.

Do you get this amount regularly?

1 Yes 2 No OTHER INCOME SOURCES (RECEIVED ANNUALLY) 1.

Money sent by relatives and friends overseas - Remittances from abroad 2.
Rental income received by you for house, land and other property 3.

Other entrepreneurial income, example from self employment 2331001 1 Yes 2 No 2341001 1 Yes 2 No 2231003 1 Yes 2 No 4.

Dividends on local and foreign investments (e.g Credit union dividends) 2351001 1 Yes 2 No 5.

Interest on local and foreign bank deposits, bonds 2361001 1 Yes 2 No 6.

Government retirement pension 7.

Pension from other former local employer 2371001 1 Yes 2 No 2371002 1 Yes 2 No 8.
Pension from former foreign employer 2371003 1 Yes 2 No 9.

Social Security (NIS), include old age/retirement pension only 2371005 1 Yes 2 No 10.

Social Security (NIS), excluding old age/retirement pension 2371005 1 Yes 2 No 11.

Insurance Annuities 12.

Public assistance 13.

Child support 14.

Allowances - alimony 2381001 1 Yes 2 No 2381002 1 Yes 2 No 2381003 1 Yes 2 No 2391003 1 Yes 2 No 15.

Allowances - financial aid 2391002 1 Yes 2 No 16.

Allowances - scholarships 2391003 1 Yes 2 No 17.


Interest from stocks, shares, Treasury bills and other investments 2361002 1 Yes 2 No 18.

All Other Income, nes 2391099 1 Yes 2 No , , , , , , , , , , , , , , , , , , , , 1 0 0 0 0 0 0 7 Page 20 SAMPLE