Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697749683580.pdf (Georgia)
aRwera 2014 PERSONAL QUESTIONNAIRE The information provided is confidential and protected by the Law of Georgia “On Official Statistics” Form #2 Sector area # Supervision area # Enumeration area # Parcel # Building # Dwelling # Ord.

# of person in dwelling # of household in dwelling 1.

PIN 2.

Sex Male Female 3.

DATE OF BIRTH 4.


PLACE OF BIRTH (PLACE OF USUAL RESIDENCE OF THE MOTHER AT THE TIME OF BIRTH) Surname, name, father’s name (DD) (MM) (YYYY) (Municipality, self-governing city) (Country, if place of birth was another country) 5.

CITIZENSHIP Georgia Other country 6.

ETHNICITY (Country) Stateless Georgian Ossetian Russian Other Abkhazian Azerbaijanian Armenian Refused to answer (Indicate ethnicity) 7.
CATEGORY OF RESIDING IN GIVEN SETTLEMENT Usual resident Temporarily absent Temporarily present Indicate the address of usual residence Indicate the duration and cause of temporary residence or absence Country Municipality, self-governing city City, borough Tbilisi district Plateau, district, etc.

Community Village Street # (Month) (Cause) (Code) (Not to be completed by the enumerator) M/R Block Building Apartm.

8.

INTERNAL MIGRATION 9.


IMMIGRATION 8.1 Have you ever lived in another settlement within the country for more than 12 months?

9.1 Have you ever lived outside the country for more than 12 months?

Yes No Yes No 8.2 Previous place of residence within the country (Municipality, self-governing city) Urban settlement (City, borough) Rural settlement 9.2 Previous country of residence (Country) 8.3 From which year have you been usually residing in the current settlement?
9.3 In which year did you move for permanent residence in Georgia from the country indicated in question 9.2?

(Year) 10.

IDP OR REFUGEE STATUS 10.1 Are you IDP or refugee?

Yes No 10.2 Where are you IDP or refugee from?

(Year) (Municipality, self-governing city) (Country) 11.

RELIGION Orthodox Catholic 12.


LANGUAGES 12.1 Native language Armenian apostolic Judaism Muslim Other Georgian Azerbaijanian Other Abkhazian Russian Ossetian Armenian (Indicate native language) None Refused to answer (Indicate religion) 12.2 Do you fluently speak Georgian language?

Yes No 13.

Education 13.1 Does he/she go to a preschool institution?
(For preschool-aged persons) Yes No 13.3 Highest level of completed education (For persons aged 10 years and over) 13.2 Are you currently studying in an educational institution?

Indicate the relevant code of education from the cover No Indicate the relevant code of highest level of completed education from the cover 14.

MARITAL STATUS (FOR PERSONS AGED 15 YEARS AND OVER, OTHER THAN EXCEPTIONAL CASES) 15.
CHILDREN (FOR WOMEN AGED 15 YEARS AND OVER, OTHER THAN EXCEPTIONAL CASES) Married Is the marriage registered?

Yes No Single Widowed Divorced 15.1 Total number of live birth children 15.2 At present how many are alive from the live birth children?

16.

STATUS OF ECONOMIC ACTIVITY (FOR PERSONS AGED 15 AND OLDER) 16.1.
Have you worked at least one hour within the period from October 29 to November 5 2014 for payment in cash or in kind or other income, or did you have work or job, which you were temporarily unable to complete for some reason?

Yes Move to question 17 No Move to question 16.2 16.2 Till 12.00 am of November 4-5, over the past four weeks, did you seek for a job or try to start your own business?
Yes Move to question 16.3 No Move to question 19 16.3 In case of suitable job or business offered where you ready to start work within two weeks?

Yes Move to question 19 No Move to question 19 17.

EMPLOYMENT STATUS Hired Self-employed (except those employed in their own peasant farm) Contributing family worker Not classified by employment status Employer (Entrepreneur, farmer with hired workers) Self-employed in their own peasant farm Member of a cooperative 18.
ECONOMIC ACTIVITY 18.1 Which enterprise/organization are you employed in?

18.2 Basically what types of goods or services are mainly produced by the enterprise/organization, private business or farm, you are employed in?

(Indicate title of organization) (Indicate the title of produced goods and services or describe the activity) 18.3 What is your position and/or what do you do at your job?

(Indicate position and/or activity in details) 19.


SOURCES OF LIVELIHOOD Wages for employment working 1 or other regular remuneration 5 6 Income from property Income from savings 10 11 Other types of state protection Dependant on other persons Income from individual labor activity 2 7 Pension 12 Foreign remittances Income from own enterprise 3 Scholarship 8 13 Other source Income from own peasant farm 4 9 Social assistance From the sources listed above indicate the number of one basic source 20.
FROM THE LISTED ITEMS DO YOU HAVE ANY HEALTH-RELATED PROBLEM, WHICH INTERFERES YOU IN YOUR DAILY ACTIVITY?

Refused to answer No difficulty Some difficulty A lot of difficulty Cannot do it at all 1) Seeing 2) Hearing 3) Walking or climbing steps 4) Remembering or concentrating 5) Communicating 6) Self-care 21.

DISABILITY STATUS Refused to answer No Clearly expressed (I group) Significantly expressed (II group) Moderately expressed (III group) Child with disabilities