A demographic survey questionnaire is one which is used to find out the statistics of a given

population such as the number of births, deaths, population census and infant mortality rate.

Demographic survey questionnaires can be used by governments, institutions and businesses

in preparation for budgets, to determine a project that would work for a certain society and to
account for the population growth and development in a country.

Below is an example of a demographic survey questionnaire for a population census:

Demographic Survey Questionnaire

1. Names of the members of the household (Only those above eighteen)

Number___________________________________

Full name__________________________________

Social security number_______________________

2. What is the average age of the people in the household?

Below 18

Between 18-24

Between 24-35

Between 35-65

Above 65

3. Gender

(i) Total number of males ____________

(ii) Total number of females___________

4.  Contact

1. i.      Physical address__________________

2. ii.      Telephone_______________________
3. iii.      Postal address_____________________
4. iv.      Fax_______________________________

5. Average level of education of the members of the household

Basic education

High School
University

Other

6. How many members of the household are:

(i)  Employed fulltime?

(ii) Employed part time?

(iii) Unemployed?

(iv) Self employed?

7. Are there any members of the family who are physically disabled?

____________________________________________

If the answer is yes, kindly state the impairment

________________________________________

8. What is the average annual income of the household?

Below $10,000

$10,000- $30,000

$ 40,000-$60,000

$60,000-$100,000

Above $ 100,000

Confidential

9. Which is the household’s main source of information?

Newspaper

Television/Radio

Internet

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