FIELD DATA COLLECTION

Describe the condition of residents 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.

Head of Family name * Family Card Number (16 digits) * Full address * RT / RW * Survey date * Surveyor name * Surveyor position *

Family composition

Number of members used to read family needs.

Total number of members * Number of elderly members * Number of school-age children * Number of disabled members *

Employment and economic capacity

Enter estimated figures per month in rupiah.

Occupation of Head of Family * Routine monthly income of Head of Family * Other monthly income * Total family income per month * Estimated value of assets owned * Routine monthly expenses * Total installments / debt per month *

Are there other family members working? *YesNo

Do you own any motorized vehicle assets? *

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

Home conditions and basic services

Choose the answer that best fits the condition during the survey.

Home ownership status * Dominant floor type * Floor condition * Dominant wall type * Wall condition * Dominant roof type * Roof condition * Electrical power * Type of drinking water * Water source for cooking * Source / fuel used for cooking * Toilet facility * Social assistance received *

Documentation

Two photos are required to describe the condition of the house as a whole.

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

Additional notes *

Double check before submitting.

DATA COLLECTION TRANSPARENCY

Names already surveyed

This list only displays the names of Heads of Household and the time of data collection. Categories and priorities are not shown.