FIELD DATA COLLECTION

Describe the residents' circumstances with neat data.

Fill out one form for each Head of Family. All questions marked with an asterisk are mandatory.

Survey identity

Basic information to retrieve data.

Name of Head of Family * Family Card (KK) number (16 digits) * Year of Family Card (KK) issuance * Month of Family Card (KK) issuance * Family Card (KK) status * Full address * RT / RW * Survey date * Surveyor name * Surveyor role *

Family composition

The number of members is used to assess family needs.

Total number of members * Number of elderly members * Number of school-age children * Number of disabled members * Marital status of Head of Family *

Occupation and economic capacity

Enter the estimated monthly figure in Rupiah.

Occupation of Head of Family * Routine monthly income of Head of Family * Other monthly income * Total monthly family income *Automatic: routine income of the Head of Family + other income. Estimated value of assets owned (information) * Routine monthly expenses * Total installments / debt per month *

Are there other family members who work? *YesNo

Do you own a motorized vehicle asset? *

Do you own other assets outside the occupied house? *YesNo

Home conditions and basic services

Select the answer that best matches the conditions during the survey.

Home ownership status * Floor length (meters) * Floor width (meters) * Estimated floor area (m²) Number of rooms * Dominant floor type * Floor condition * Type of widest wall * Wall condition * Dominant roof type * Roof condition * Electricity power * IDPEL number * Monthly electricity cost *

Do you use the internet? *YesNo

Type of drinking water * Water source for cooking * Source / fuel used for cooking * Toilet facilities * Social assistance received *

Documentation

Two photos are required to fully depict the condition of the house.

Front view of the house photo *JPG, PNG, or WEBP · each photo is automatically compressed Bathroom photo *JPG, PNG, or WEBP · each photo is automatically compressed

House condition assessment active after both photos are selected.

Additional notes *

Double-check before submitting.

Socio-Economic Citizen Survey

Describe the residents' circumstances with neat data.

Survey identity

Family composition

Occupation and economic capacity

Home conditions and basic services

Documentation

Surveyed names

Describe the residents' circumstances with neat data.

Survey identity

Family composition

Occupation and economic capacity

Home conditions and basic services

Documentation

Surveyed names

Owner-only access