FIELD FORM

Understand family conditions more comprehensively.

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Household identity

Starting from basic information and verification results.

iField content can be edited at any time. Fields marked with * are required.

Head of household name * Survey date Full address * RT RW Verification * Assistance intervention

Population

Family Card status Family Card year Family Card Number (16 digits)

Family Card photoJPG/PNG, maximum 5 MB

Further filling skippedFor this status, questions after Population do not need to be filled.

Family members

Record the condition of each family member living together.

1 anggota Add one by one so none are missed.

＋Add member

Home & utilities

Describe the condition of the house, sanitation, land assets, and monthly needs.

House condition

Photo of the house front with the respondent *JPG/PNG, maximum 5 MB

Roof photo *JPG/PNG, maximum 5 MB

Wall photo *JPG/PNG, maximum 5 MB

Floor photo *JPG/PNG, maximum 5 MB

Toilet photo *JPG/PNG, maximum 5 MB

RoofWallFloorToiletFloor area (m²)

Number of households occupyingNumber of rooms

Sanitation

Toilet usageToilet typeLandfill

Residential status & land assets

Building ownership statusResidential land statusLand and Building Tax (PBB) value per yearProof of land ownershipBuilding rental cost

Electricity & utilities

Type of lightingElectricity powerPLN customer numberElectricity cost / monthNumber of electricity metersInternet cost / month

Water & cooking

Drinking water sourceHow to obtain waterDrinking water cost / monthMain cooking fuelFuel cost / monthCooking expenses / month

Household expenses

Trash fee / monthInstallment / monthTotal phone credit for all members / monthAverage food / weekNon-food routine / monthNon-food routine / yearOther expenses / year

Asset ownership

TVKulkasMesin cuciSepeda motorMobilLaptop/komputerTabunganTidak ada

EmasQuantity

RumahQuantity

TanahArea / quantity

SawahArea / quantity

Hewan ternakQuantity

House location

LatitudeLongitude

⌖Use my location

Notes

Officer notes / special conditions

Summary & save

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Baratajaya Resident Socio-Economic Survey

Socio-Economic Survey