Household Survey
Users
SnackBar
LocMun
Household Survey
Section A: General Information
Check In
Latitude
Longitude
Nature of Dwelling
House
Business
Block of Flats
Hostel
Home of Elderly
Empty Plot
Other (Specify)
Dwelling Name
Title
Full Names
Known As
Last Name
Identity Number
Nationality
Gender
Male
Female
Other
Type of Resident
Owner
Tenant
Children
Contact Cell Number
Alternative Cell Number
Home Contact Number
Email Address
Total Family Members Living Here
Total Family Members Working
Total Pensioners Living Here
Type of Employment
Employed
Self Employed
Pensioner
Not Employed
If 'Not Employed', when did you last work?
If 'Pensioner', do you receive a grant?
Yes
No
Name of Employer
Contact Person
Contact Person's Number
Your Work Telephone Number
Your Work Fax Number
Your Work Email Address
Total Household Income
R300 - R1.000
R1.001 - R5.000
R5.001 - R10.000
R10.001 - R20.000
R20.001 and above
Next of Kin
Relationship
Contact Number
Email Address
Section B: Household Information
Property Number / House Number
Street Name
If Business, please provide
Registration Number
VAT Number
Tenure Status
Owned
Rented
Bond
Number of back rooms
Number of tenants
Condition of Property
Good
Bad
Fair
Vandilized/Destroyed
Is this property Indigent registered?
Yes
No
Reasons for NO Indigent Registration
Section C: Municipal Services
Do you receive Municipal Accounts?
Yes
No
Any reason for not receiving
How are Municipal Accounts received?
Email
Post
Other
If Other, please specify
Municipal Services: Water
Is there a Water Meter?
Yes
No
What type of meter is it?
Prepaid
Conventional
Water Meter Number
Water Meter Reading
Water Meter Picture
Water Meter Reading Picture
Condition of the Water Meter
Good
Bad / Leaking
Is the Water Meter by-passed
Yes
No
Municipal Services: Electrivity
Is there an Electricity Meter?
Yes
No
What type of meter is it?
Prepaid
Conventional
Electricity Meter Number
Electricity Meter Reading
Electricity Meter Picture
Electricity Meter Reading Picture
Condition of the Electricity Meter
Good
Bad
Is the Electricity Meter by-passed
Yes
No
Municipal Services: Refuse Bins & Sewer
Is there Refuse bins?
Yes
No
How many refuse bins?
How many toilets?
Is the toilet(s) working?
Working
Not Working
Toilet Picture
Section D: Payment Status
Are you paying Municipal Accounts?
Yes
No
Any reason for not paying?
If 'Other', please specify.
When do you pay Municipal Services?
Between 1st & 15th
Between 16th & 31st
Section E: Signature
Picture of Person Providing Information
Picture of Property
Signature of Person Providing Information
Check Out
Submit
No
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