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First name
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City/town
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Select a country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (the Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (the Democratic People's Republic of)
Korea (the Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (the Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Section A: Personal Identification
Surname
First Name
Middle Name
Initials
South African ID Number
Type of Alternative ID
Passport Number
Birth Certificate Number
None
Alternative ID Number
Date of Birth
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Enable
Section B: Equity and Nationality
Gender
Male
Female
Unknown
Nationality
South Africa
SADC except SA (i.e. NAM to ZAI)
Namibia
Botswana
Zimbabwe
Angola
Mozambique
Lesotho
Swaziland
Malawi
Zambia
Mauritius
Tanzania
Seychelles
Zaire
Rest of Africa
European Countries
Asian Countries
North American Countries
Central and South American Countries
Australia and New Zealand
Other and rest of Oceania
N/A: Institution
Unknown
Home Language
English
Afrikaans
Other
South African Sign Language
sePedi [also known as Northern Sotho / Sesotho sa Lebowa]
seSotho
seTswana
siSwati
tshiVenda
isiXhosa
xiTsonga
isiZulu
isiNdebele
Unknown
Citizen Resident Status Code
South Africa
Other
Dual (SA plus other)
Permanent Resident
Unknown
Section C: Health and Functioning Status
Seeing
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Hearing
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Communicating
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Walking
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Remembering
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Self Care
1 - No difficulty
2 - Some difficulty
3 - A lot of difficulty
4 - Cannot do at all
6 - Cannot yet be determined
60 - Multiple difficulties
70 - May have difficulty
80 - Former difficulty, none now
Section D: Contact Details
Telephone
Fax
Cell Phone
E-Mail
Section E: Physical Address
Street Postal Code
Street Address
Suburb
Town/City
Municipality
Abaqulusi
Aberdeen Plain
Aganang
Albert Luthuli
Amahlathi
Ba-Phalaborwa
Baviaans
Beaufort West
Bela-Bela
Benede Oranje
Bergrivier
Bitou
Blouberg
Blue Crane Route
Breede River
Breede River/Winelands
Breede Valley
Buffalo City
Bushbuckridge
Camdeboo
Cape Agulhas
Cape Town Metro
Cederberg
Central Karoo
Dannhauser
Delmas
Diamondfields
Dihlabeng
Dikgatlong
Dipaleseng
Ditsobotla
Dr JS Moroka
Drakenstein
eDumbe
Ekurhuleni Metro
Elundini
Emalahleni EC
Emalahleni MP
Emfuleni
Emnambithi-Ladysmith
Emthanjeni
eNdondakusuka
Endumeni
Engcobo
eThekwini Metro
Ezingoleni
Fetakgomo
Gaints Game Reserve
Gamagara
Gariep
Ga-Segonyana
George
Govan Mbeki
Great Kei
Greater Giyani
Greater Groblersdal
Greater Kokstad
Greater Letaba
Greater Marble Hall
Greater Taung
Greater Tubatse
Greater Tzaneen
Hantam
Hessequa
Hibiscus Coast
Highlands
Hlabisa
Ikwezi
Imbabazane
Impendle
Indaka
Ingwe
Inkwanca
Intsika Yethu
Inxuba Yethemba
Johannesburg Metro
Jozini
Kagisano
Kai Garib
Kalahari
Kamiesberg
Kannaland
Kareeberg
Karoo Hoogland
Kgatelopele
Kgetlengrivier
Kh?i-Ma
Khara Hais
Kheis
King Sabata Dalindyebo
Knysna
Kopanong
Kouga
Kou-Kamma
Kruger National Park
Kungwini
Kwa Sani
KwaDukuza
Laingsburg
Lekwa
Lekwa-Teemane
Lepele-Nkumpi
Lephalale
Lesedi
Letsemeng
Lowveld
Lukanji
Madibeng
Mafikeng
Mafube
Magareng
Makana
Makhado
Makhuduthamaga
Maletswai
Maluti a Phofung
Mamusa
Mangaung
Mantsopa
Maphumulo
Maquassi Hills
Maruleng
Masilonyana
Matatiele
Matjhabeng
Matlosana
Matzikama
Mbhashe
Mbizana
Mbombela
Mbonambi
Merafong City
Metsimaholo
Mhlontlo
Midvaal
Mier
Mkhambathini
Mkhomazi Wilderness Area
Mkhondo
Mnquma
Modimolle
Mogalakwena
Mogale City
Mohokare
Molemole
Molopo
Mooi Mpofana
Mookgopong
Moqhaka
Moretele
Moses Kotane
Moshaweng
Mossel Bay
Msinga
Msukaligwa
Msunduzi
Mthonjaneni
Mtubatuba
Musina
Mutale
Nala
Naledi FS
Naledi NW
Nama Khoi
Ndlambe
Ndwedwe
Nelson Mandela Metro
Newcastle
Ngqushwa
Ngwathe
Nkandla
Nketoana
Nkomazi
Nkonkobe
Nokeng tsa Taemane
Nongoma
Nquthu
Ntabankulu
Ntambanana
Nxuba
Nyandeni
Okhahlamba
Oudtshoorn
Overberg
Overstrand
Phokwane
Phumelela
Pixley Ka Seme
Polokwane
Port St Johns
Potchefstroom
Prince Albert
Qaukeni
Ramotshere Moiloa
Randfontein
Ratlou
Renosterberg
Richmond
Richtersveld
Rustenburg
Sakhisizwe
Saldanha Bay
Senqu
Setsoto
Siyancuma
Siyathemba
Sol Plaatjie
South Cape
St Lucia Park
Stellenbosch
Steve Tshwete
Sunday's River Valley
Swartland
Swellendam
Thaba Chweu
Thabazimbi
The Big Five False Bay
Theewaterskloof
Thembelihle
Thembisile
Thulamela
Tokologo
Tsantsabane
Tshwane Metro
Tsolwana
Tswaing
Tswelopele
Ubuhlebezwe
Ubuntu
Ulundi
Umdoni
Umhlabuyalingana
uMhlathuze
Umjindi
uMlalazi
uMngeni
uMshwathi
Umsobomvu
Umtshezi
UMuziwabantu
Umvoti
Umzimkhulu
Umzimvubu
Umzumbe
UPhongolo
Utrecht
Ventersdorp
Vulamehlo
West Coast
Westonaria
Witzenberg
Unknown
Area Type
Urban
Rural
Unknown
Province
Western Cape
Eastern Cape
Northern Cape
Freestate
KwaZulu-Natal
North West
Gauteng
Mpumalanga
Limpopo
Unknown
Section F: Postal Address
Postal Address
Postal Suburb
Postal Town/City
Postal Code
Postal Municipality
Abaqulusi
Aberdeen Plain
Aganang
Albert Luthuli
Amahlathi
Ba-Phalaborwa
Baviaans
Beaufort West
Bela-Bela
Benede Oranje
Bergrivier
Bitou
Blouberg
Blue Crane Route
Breede River
Breede River/Winelands
Breede Valley
Buffalo City
Bushbuckridge
Camdeboo
Cape Agulhas
Cape Town Metro
Cederberg
Central Karoo
Dannhauser
Delmas
Diamondfields
Dihlabeng
Dikgatlong
Dipaleseng
Ditsobotla
Dr JS Moroka
Drakenstein
eDumbe
Ekurhuleni Metro
Elundini
Emalahleni EC
Emalahleni MP
Emfuleni
Emnambithi-Ladysmith
Emthanjeni
eNdondakusuka
Endumeni
Engcobo
eThekwini Metro
Ezingoleni
Fetakgomo
Gaints Game Reserve
Gamagara
Gariep
Ga-Segonyana
George
Govan Mbeki
Great Kei
Greater Giyani
Greater Groblersdal
Greater Kokstad
Greater Letaba
Greater Marble Hall
Greater Taung
Greater Tubatse
Greater Tzaneen
Hantam
Hessequa
Hibiscus Coast
Highlands
Hlabisa
Ikwezi
Imbabazane
Impendle
Indaka
Ingwe
Inkwanca
Intsika Yethu
Inxuba Yethemba
Johannesburg Metro
Jozini
Kagisano
Kai Garib
Kalahari
Kamiesberg
Kannaland
Kareeberg
Karoo Hoogland
Kgatelopele
Kgetlengrivier
Kh?i-Ma
Khara Hais
Kheis
King Sabata Dalindyebo
Knysna
Kopanong
Kouga
Kou-Kamma
Kruger National Park
Kungwini
Kwa Sani
KwaDukuza
Laingsburg
Lekwa
Lekwa-Teemane
Lepele-Nkumpi
Lephalale
Lesedi
Letsemeng
Lowveld
Lukanji
Madibeng
Mafikeng
Mafube
Magareng
Makana
Makhado
Makhuduthamaga
Maletswai
Maluti a Phofung
Mamusa
Mangaung
Mantsopa
Maphumulo
Maquassi Hills
Maruleng
Masilonyana
Matatiele
Matjhabeng
Matlosana
Matzikama
Mbhashe
Mbizana
Mbombela
Mbonambi
Merafong City
Metsimaholo
Mhlontlo
Midvaal
Mier
Mkhambathini
Mkhomazi Wilderness Area
Mkhondo
Mnquma
Modimolle
Mogalakwena
Mogale City
Mohokare
Molemole
Molopo
Mooi Mpofana
Mookgopong
Moqhaka
Moretele
Moses Kotane
Moshaweng
Mossel Bay
Msinga
Msukaligwa
Msunduzi
Mthonjaneni
Mtubatuba
Musina
Mutale
Nala
Naledi FS
Naledi NW
Nama Khoi
Ndlambe
Ndwedwe
Nelson Mandela Metro
Newcastle
Ngqushwa
Ngwathe
Nkandla
Nketoana
Nkomazi
Nkonkobe
Nokeng tsa Taemane
Nongoma
Nquthu
Ntabankulu
Ntambanana
Nxuba
Nyandeni
Okhahlamba
Oudtshoorn
Overberg
Overstrand
Phokwane
Phumelela
Pixley Ka Seme
Polokwane
Port St Johns
Potchefstroom
Prince Albert
Qaukeni
Ramotshere Moiloa
Randfontein
Ratlou
Renosterberg
Richmond
Richtersveld
Rustenburg
Sakhisizwe
Saldanha Bay
Senqu
Setsoto
Siyancuma
Siyathemba
Sol Plaatjie
South Cape
St Lucia Park
Stellenbosch
Steve Tshwete
Sunday's River Valley
Swartland
Swellendam
Thaba Chweu
Thabazimbi
The Big Five False Bay
Theewaterskloof
Thembelihle
Thembisile
Thulamela
Tokologo
Tsantsabane
Tshwane Metro
Tsolwana
Tswaing
Tswelopele
Ubuhlebezwe
Ubuntu
Ulundi
Umdoni
Umhlabuyalingana
uMhlathuze
Umjindi
uMlalazi
uMngeni
uMshwathi
Umsobomvu
Umtshezi
UMuziwabantu
Umvoti
Umzimkhulu
Umzimvubu
Umzumbe
UPhongolo
Utrecht
Ventersdorp
Vulamehlo
West Coast
Westonaria
Witzenberg
Unknown
Postal Area Type
Urban
Rural
Unknown
Postal Province
Western Cape
Eastern Cape
Northern Cape
Freestate
KwaZulu-Natal
North West
Gauteng
Mpumalanga
Limpopo
Unknown
Section G: Socio Economic Status
Socio Economic Status
Employed
Unemployed
Unknown
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