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pdfU.S. DEPARTMENT OF COMMERCE
AN EQUAL OPPORTUNITY EMPLOYER
Economics and Statistics Administration
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville IN 47132-0001
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-46(2010) (8-2008) (Ver. M)
The American Community Survey
Form Enclosed
YOUR RESPONSE
IS REQUIRED BY LAW
USCENSUSBUREAU
THE
American Community Survey
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
Dear Resident:
I recently sent a letter to your household about the American Community Survey.
Enclosed is a questionnaire and information about the survey. Please complete the
questionnaire and mail it back as soon as possible in the postage-paid envelope.
The U.S. Census Bureau is conducting this survey and chose your address, not you
personally, as part of a randomly selected sample.
Some households, including yours, will receive both the American Community
Survey and the 2010 Census this year. Your response to both is required by U.S.
law. The Census Bureau is required by U.S. law to keep your answers confidential.
The American Community Survey collects critical up-to-date information used to
meet the needs of communities across the United States. For example, results from
this survey are used to decide where new schools, hospitals, and fire stations are
needed. This information also helps communities plan for the kinds of emergency
situations that might affect you and your neighbors, such as floods and other natural
disasters.
The enclosed brochure answers frequently asked questions about the American
Community Survey. If you need help filling out the questionnaire, please use the
enclosed guide or call our toll-free number (1-800-354-7271).
Thank you.
Sincerely,
Steve H. Murdock
Director, U.S. Census Bureau
Enclosures
ACS-13(L)
Your Guide for
THE
American
Community
Survey
This guide gives helpful information on
completing your survey form. If you need more
help, call 1-800-354-7271. The telephone call is
free. After you have completed your survey
form, please return it in the postage-paid
envelope we have provided.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
USCENSUSBUREAU
ACS-30(2009)
(8-2008)
Page
Your
Answers are Confidential and
Required by Law
2
How
to Fill Out the Survey Form
3
Examples
of Printed and Marked Entries
3
Instructions
for Completing the Survey Questions
3
What
the Survey is About – Some Questions
and Answers
16
Why
the Census Bureau Asks Certain Questions
16
YOUR ANSWERS ARE CONFIDENTIAL AND REQUIRED
BY LAW
The law, Title 13, Sections 141, 193, and 221 of the U.S. Code,
authorizing the American Community Survey, also provides that
your answers are confidential. No one except Census Bureau
employees may see your completed form and they can be fined
and/or imprisoned for any disclosure of your answers.
The same law that protects the confidentiality of your answers
requires that you provide the information asked in this survey
to the best of your knowledge.
ACS-30(2009) (8-2008)
Page 2
HOW TO FILL OUT THE AMERICAN COMMUNITY
SURVEY FORM
Please mark the category or categories as they apply to your household.
Some questions ask you to print the information. See Examples below.
Make sure you answer questions for each person in this household. If
anyone in the household, such as a roomer or boarder, does not want to
give you his or her personal information, print at least the person’s name
and answer questions 2 and 3. An interviewer may telephone to get
the information from that person.
There may be a question you cannot answer exactly. For example, you
may not know the age of an older person or the price for which your
house would sell. Ask someone else in your household; if no one knows,
give your best estimate.
Read these instructions and also follow the instructions provided
throughout the questionnaire. These instructions will help you understand
the questions and to answer them correctly. If you need assistance, call
1-800-354-7271. The telephone call is free.
EXAMPLES OF PRINTED AND MARKED ENTRIES
14
a. Does this person speak a language other than
English at home?
X
Yes
No ➜ SKIP to question 15a
b. What is this language?
Korean
For example: Korean, Italian, Spanish, Vietnamese
23 In what year did this person last get married?
Year
1998
INSTRUCTIONS FOR COMPLETING THE SURVEY QUESTIONS
List the name of each person who lives at this address. If you are not sure if
you should list a person, see the guidelines on the front page of the form.
If you are still not sure, call 1-800-354-7271 for help.
In the space labeled Person 1, print the name of the household member
living or staying here in whose name the house or apartment is owned,
being bought, or rented.
If there is no such person, any adult household member can be Person 1.
If there are more than 5 people in your household, please provide the
name of each additional person on page 4. For each additional person
listed on page 4, you should also provide this person’s sex and age.
Complete this form for the first five people listed on pages 2, 3, and 4, and
mail it back in the enclosed envelope as soon as possible. An interviewer
may telephone to obtain information for the additional persons.
If no one is living or staying at this address for more than 2 months, do not
list any names on pages 2, 3, and 4. Complete only pages 5, 6, and 7, and
return the form.
ACS-30(2009) (8-2008)
Page 3
ANSWER PERSON QUESTIONS 1 THROUGH 6 FOR THE FIRST FIVE
PEOPLE LISTED ON PAGES 2, 3, AND 4 OF THE QUESTIONNAIRE.
1. Print the person’s Last Name, First Name, and Middle Initial (MI) in
the spaces provided.
2. If the person is related to Person 1 by birth, marriage, or adoption,
but is not the Husband or wife, Biological son or daughter,
Adopted son or daughter, Stepson or stepdaughter, Brother or
sister, Father or mother, Grandchild, Parent-in-law, Son-in-law
or daughter-in-law, of Person 1, mark the "Other relative" box.
Therefore, a niece or nephew of Person 1 would be categorized as
"Other relative."
If a person is not related to Person 1, mark the applicable box. A
"Roomer or boarder" is someone who occupies room(s) and makes
cash or non-cash payment(s). A "Housemate or roommate" is
someone sharing the house/apartment (but who is not romantically
involved) with Person 1. A "Housemate or roommate" is also 15
years old or over and who shares living quarters primarily to share
expenses. An "Unmarried partner," also known as a domestic
partner, is a person who shares a close personal relationship with
Person 1. A "Foster child" is someone under the age of 21 who is
involved in the formal foster care system. For all other people who are
not related to person 1, mark the "Other nonrelative" box.
3. Mark one box to indicate this person’s biological sex.
4. For each person, print this person’s age and month, day, and year of
birth. Print the age at the last birthday. Do not round the age up if
this person is close to having a birthday. If the exact age is not known,
provide an estimate. Print "0" for babies less than 1 year old.
Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not
races.
5. A person is of Hispanic, Latino, or Spanish origin if the person’s origin
(ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban,
Argentinean, Colombian, Costa Rican, Dominican, Ecuadoran,
Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other
Spanish-speaking countries of the Caribbean or Central or South
America, or from Spain.
The term Mexican Am. refers to persons of Mexican-American origin or
ancestry.
If you mark the "Yes, another Hispanic, Latino, or Spanish origin"
box, print the name of the specific origin.
If a person is not of Hispanic, Latino, or Spanish origin, answer this
question by marking the "No, not of Hispanic, Latino, or Spanish
origin" box.
This question should be answered for ALL persons.
6. Mark all boxes for the appropriate races.
The concept of race, as used by the Census Bureau, reflects
self-identification by individuals according to the race or races with
which they identify.
The instruction before question 5, "For this survey, Hispanic origins are
not races" reflects the federal government’s treatment of Hispanic origin
and race as separate and distinct concepts. People who identify their
origin as Hispanic, Latino, or Spanish may be of any race.
People may choose to provide two or more races either by marking two
or more race response boxes, by providing multiple write-in responses, or
by some combination of marking boxes and writing in responses.
If you mark the "American Indian or Alaska Native" box, also print
the name of the tribe(s) in which the person is enrolled. If the person
is not enrolled in a tribe, print the name of the principal tribe.
ACS-30(2009) (8-2008)
Page 4
If you mark the "Other Asian" box, print the name of the specific
race(s) or group(s) in the space provided. The category "Other
Asian" includes persons who identify themselves as Burmese,
Hmong, Indonesian, Laotian, Thai, Pakistani, Cambodian, Sri
Lankan, and so on.
If you mark the "Other Pacific Islander" box, print the name of
the specific race(s) or group(s) in the space provided. The category
"Other Pacific Islander" includes persons who identify themselves as Fijian, Tongan, Polynesian, Tahitian, and so on.
If you mark the "Some other race" box, print the race(s) or
group(s) in the space provided.
This question should be answered for ALL persons.
ANSWER HOUSING QUESTIONS 1 THROUGH 21 FOR THE HOUSE,
APARTMENT, OR MOBILE HOME AT THE ADDRESS ON THE MAILING
LABEL.
1.
Mark only one category.
Count both occupied and vacant apartments in the house or
building. Do not count stores or office space.
Detached means there is open space on all sides, or the house is
joined only to a shed or garage. Attached means that the house is
joined to another house or building by at least one wall that goes
from ground to roof. An example of A one-family house
attached to one or more houses is a house in a row of houses
attached to one another, sometimes referred to as a townhouse.
A mobile home that has had one or more rooms added or built
onto it should be considered as A one-family house detached
from any other house. If only a porch or shed has been added to
a mobile home, it should be considered as a mobile home.
Towable RVs, such as travel trailers or fifth-wheel trailers, should be
considered as A mobile home. Self-propelling RVs or motorhomes
should be considered as a Boat, RV, van, etc.
2.
Mark the box that corresponds to the year in which the original
construction was completed, not the time of any later remodeling,
additions, or conversions.
If the building was first built in 2000 or later, enter the exact year
it was built.
If you live on a boat or in a mobile home, enter the year
corresponding to the model year in which it was manufactured.
If you do not know the year the building was first built, enter your
best estimate.
3.
Enter the month and year that Person 1 listed on page 2 last
moved into this house, apartment, or mobile home.
4.
Complete this question if you live in a one-family house or in a
mobile home; include only land that you own or rent.
The number of acres is the acreage on which the house or mobile
home is located; include adjoining land you rent for your use.
6.
Complete this question if you live in a one-family house or
mobile home. A business, such as a grocery store or barber shop,
is easily recognized from the outside and usually has a separate
entrance. A medical office is a doctor’s or dentist’s office
regularly visited by patients.
ACS-30(2009) (8-2008)
Page 5
7b. Include all rooms intended to be used as bedrooms in this house,
apartment, or mobile home, even if they are currently being used for
other purposes.
Print "0" for an efficiency or studio apartment that does not have a
separate bedroom. Your response to this question (7b) should be
smaller than the number of rooms reported in question 7a.
8a. Mark "Yes" to "hot and cold running water" even if the unit has
hot water only part of the time.
8d. Mark "Yes" to "sink with a faucet" if the sink is inside the house,
apartment or mobile home and the water can be turned on and off
with a faucet.
8e. Mark "Yes" to "a stove or range" if the stove or range is inside
the house, apartment or mobile home. Portable cooking equipment
is not considered a stove or range.
8g. Mark "Yes" to "telephone service ..." if (1) there is a telephone in
working order, and someone receives service at this house,
apartment, or mobile home; or (2) if someone has a cell phone from
which you can both make and receive calls. If service has been
discontinued because of nonpayment or any other reason, mark the
"No" box.
9.
10.
Include company cars, vans or SUVs (including police cars and
taxicabs) and company trucks of one-ton (2,000 pounds) capacity or
less that are regularly kept at home and used by household members
for nonbusiness purposes. DO NOT count (1) cars or trucks
permanently out of working order, or (2) motorcycles or other
recreational vehicles.
Mark ONE category for the fuel used MOST to heat this house,
apartment, or mobile home. In buildings containing more than one
apartment, you may obtain this information from the owner,
manager, or janitor.
Solar energy is provided by a system that collects, stores, and
distributes heat from the sun. Other fuel includes any fuel not
listed separately, such as purchased steam, fuel briquettes, and
waste material.
11a-11d.
If your house, apartment, or mobile home is rented, enter the costs
for utilities and fuels only if you pay for them in addition to the
monthly rent.
If you live in a condominium, enter the costs for utilities and fuels
only if you pay for them in addition to your condominium fee.
If your fuel and utility costs are included in your rent or condominium
fee, mark the "Included in rent or condominium fee" box.
DO NOT enter any dollar amounts.
For items 11a and 11b, report LAST MONTH’S COSTS. For items 11c
and 11d, report total costs for the PAST 12 MONTHS.
Estimate as closely as possible if you do not know exact costs. If you
have lived in this house, apartment, or mobile home less than one
year, estimate the costs for the PAST 12 MONTHS in 11c and 11d.
Report amounts even if your bills are unpaid or paid by someone
else. If the bills include utilities or fuel used also by another
apartment or a business establishment, estimate the amounts for
your house or apartment only. If gas and electricity are billed
together, enter the combined amount in 11a and mark the
"Included in electricity payment entered above" box in
item 11b.
ACS-30(2009) (8-2008)
Page 6
13.
A condominium is housing in which the apartments, houses, or
mobile homes in a building or development are individually owned,
but the common areas, such as lobbies and halls, are jointly owned.
Occupants of a cooperative should mark the "No" box.
A condominium fee is normally assessed by the condominium
owners’ association for the purpose of improving and maintaining
the common areas. Enter a monthly amount even if it is unpaid or
paid by someone else. If the amount is paid on some other periodic
basis, see the instruction for question 15a below on how to change
it to a monthly amount.
14.
Housing is owned if the owner or co-owner lives in it.
If the house, apartment, or mobile home is mortgaged or there is a
contract to purchase, mark the "Owned by you or someone in this
household with a mortgage or loan? Include home equity
loans." box. If there is no mortgage or other debt, mark the
"Owned by you or someone in this household free and clear
(without a mortgage or loan)?" box. If the house, apartment, or
mobile home is owned but the land is rented, mark one of the
"owned" categories. If the mobile home is owned without an
installment loan, but there is a mortgage on the land, mark the
"Owned by you or someone in this household with a mortgage
or loan? Include home equity loans." box.
If any money rent is paid, even if the rent is paid by people who are
not members of your household, or paid by a federal, state, or local
government agency, mark the "Rented?" box.
If the unit is not owned or being bought by a member of this
household and if money rent is not paid or contracted, mark the
"Occupied without payment of rent?" box. The unit may be
owned by friends or relatives who live elsewhere and who allow
you to occupy this house, apartment, or mobile home without
charge. A house or apartment may be provided as part of wages or
salary. Examples are: caretaker’s or janitor’s house or apartment;
parsonages; tenant farmer or sharecropper houses for which the
occupants do not pay rent; or military housing.
15a. Report the rent agreed to or contracted for, even if the rent for your
house, apartment, or mobile home is unpaid or paid by someone else.
If rent is paid:
Multiply
rent by:
By the day . . . . . . . . 30
By the week . . . . . . . 4
Every other week . . . . 2
If rent is paid:
Divide
rent by:
4 times a year . . . . . . . 3
2 times a year . . . . . . 6
Once a year . . . . . . . . 12
15b. If meals are included in the monthly rent payment, or you must
contract for meals or a meal plan in order to live in this house,
apartment, or mobile home, mark the "Yes" box.
ANSWER HOUSING QUESTIONS 16 THROUGH 20 IF YOU OR ANY
MEMBER OF THIS HOUSEHOLD OWNS OR IS BUYING THIS HOUSE,
APARTMENT, OR MOBILE HOME.
16.
Enter your best estimate of the value of the property; that is, how
much you think the property would sell for if it were on the market.
If this is a house, include the value of the house, the land it is on,
and any other structures on the same property. If the house is
owned but the land is rented, estimate the combined value of the
house and the land. If this is a condominium unit, estimate the value
for the condominium, including your share of the common
elements. If this is a mobile home, include the value of the mobile
home and the value of the land only if you own the land.
ACS-30(2009) (8-2008)
Page 7
17.
Report taxes for all taxing jurisdictions (city or town, county,
state, school district, etc.) even if they are included in your
mortgage payment, not yet paid or paid by someone else, or are
delinquent. DO NOT include taxes past due from previous years.
18.
When premiums are paid other than on a yearly basis, convert to
a yearly basis. Enter the yearly amount even if no payment was
made during the past year.
19a. The word mortgage indicates all types of loans secured by real
estate.
19b. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see the
instructions for 15a to change it to a monthly amount.
Include payments on first mortgages and contracts to purchase only.
Report payments for second or junior mortgages and home equity
loans in 20b.
If this is a mobile home, report payments on installment loans but
DO NOT include personal property taxes, site rent, registration fees,
and license fees on the mobile home and site. Report these fees in
item 21.
20a. A second mortgage or home equity loan is also secured by real estate.
You must have a first mortgage in order to have a second mortgage.
You may have a home equity loan and other mortgages on the
property or the home equity loan may be the only mortgage.
20b. Enter a monthly amount even if it is unpaid or paid by someone
else. If the amount is paid on some other periodic basis, see
instructions for 15a to change it to a monthly amount. Include
payments on all second or junior mortgages or home equity loans.
ANSWER HOUSING QUESTION 21 IF THIS IS A MOBILE HOME THAT
YOU OWN OR ARE BUYING.
21.
Report an amount even if your bills are unpaid or are paid
by someone else.
Include payments for personal property taxes, land or site rent,
registration fees and license fees. DO NOT include real estate taxes
already reported in 17. Report the total annual amount even if you
make payments in two or more installments. Estimate as closely as
possible when you don’t know exact costs.
ANSWER PERSON QUESTIONS 7 THROUGH 16 FOR ALL PERSONS
ON PAGES 2, 3, AND 4.
Questions 7-48 are a continuation of the questions for each person.
(Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)
7. For people born in the United States:
Mark the "In the United States" box and then print the name of
the state in which the person was born. If the person was born in
Washington, D.C., print "District of Columbia."
For people born outside the United States:
Mark the "Outside the United States" box, and then print the
name of the foreign country or Puerto Rico, Guam, etc. where the
person was born. Use current boundaries, not boundaries at the time
of the person’s birth. For example, specify either Northern Ireland or
the Republic of Ireland (Eire); North or South Korea; England,
Scotland, or Wales (not Great Britain or United Kingdom). Specify the
particular country or island in the Caribbean (for example, Jamaica,
not West Indies).
ACS-30(2009) (8-2008)
Page 8
8. If the person was born in the United States (50 states and the District of
Columbia), mark the "Yes, born in the United States" box. If the
person was born in Puerto Rico, Guam, the U.S. Virgin Islands, or
Northern Marianas, mark the "Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas" box. If the person was
born outside the United States (50 states and the District of Columbia)
or at sea and had at least one parent who was a U.S. citizen at the time
of the person’s birth, mark the "Yes, born abroad of U.S. citizen
parent or parents" box. Mark the "Yes, U.S. citizen by
naturalization" box only if this person was born outside the United
States (50 states and the District of Columbia) and has completed the
naturalization process and is now a United States citizen. In the boxes
below "Print year of naturalization," print the four-digit year this
person completed the formal naturalization process. If this person is not
a U.S. citizen, mark the "No, not a U.S. citizen" box. Legal Permanent
Residents (LPRs) or "green card" holders, or other non-naturalized
immigrants or visitors to the U.S. are not citizens of the United States
and therefore should mark the "No, not a U.S. citizen" box.
9. If the person came to live in the United States (that is, the 50 states
and the District of Columbia) more than once, enter the latest year
he or she came to live in the United States.
10a. A public school is any school or college that is controlled and
supported primarily by a local, county, state, or federal government.
Schools are private if supported and controlled primarily by religious
organizations or other private groups. Home school applies to parental
guided education outside of a public or private school for grades 1–12.
11. Mark only one box to indicate the highest grade or level of schooling the
person has COMPLETED or the highest degree the person received.
Report schooling completed in foreign or ungraded schools as the
equivalent level of schooling in the regular American school system.
Mark the "GED or alternative credential" box for persons who did not
receive a regular high school diploma but completed high school by
receiving a GED or other formal recognition of high school completion
from a school or governmental authority.
If the person has not completed any college courses for credit, mark
the highest level completed below the college level. If the person has
not completed enough credit to be counted as a sophomore, mark the
"Some college credit, but less than 1 year of college credit" box.
For the "Professional degree beyond a bachelor’s degree"
category, DO NOT include certificates or diplomas for training in specific
trades or occupations such as computer and electronics technology,
medical assistant, or cosmetology. DO NOT include post-bachelor’s
certificates that are related to occupational training in such fields as
teaching, accounting, or engineering.
12. Answer this question only if the person has a bachelor’s degree or
higher and print the specific major of this person’s bachelor’s
degree. If this person has more than one bachelor’s degree or more
than one major, print the names of the specific majors for all of this
person’s bachelor’s degree(s).
13. Print the ancestry group(s). Ancestry refers to the person’s ethnic
origin or descent, "roots," or heritage. Ancestry may also refer to the
country of birth of the person or the person’s parents or ancestors
before their arrival in the United States. Answer this question for ALL
persons, regardless of citizenship status.
Do not report a religious group as a person’s ancestry.
Persons who have more than one origin and cannot identify with a
single ancestry group may report two ancestry groups (for example:
German, Irish).
14a. Mark the"Yes" box if the person sometimes or always speaks a
language other than English at home.
Mark the "No" box if the person speaks only English, or if a non-English
language is spoken only at school or is limited to a few expressions
or slang.
14b. If this person speaks more than one non-English language and cannot
determine which is spoken more often, report the one the person first
learned to speak.
ACS-30(2009) (8-2008)
Page 9
15a. If the person did not live in the United States or Puerto Rico one year
ago, mark the "No, outside the United States and Puerto Rico"
box and print the name of the foreign country, or U.S. Virgin Islands,
Guam, etc., where the person lived. Be specific when printing the
name of the foreign country, for example, specify whether Northern
Ireland or the Republic of Ireland (Eire); North or South Korea;
England, Scotland or Wales (not Great Britain or United Kingdom).
Specify the particular country or island in the Caribbean (not, for
example, West Indies). Then SKIP to question 16.
If the person lived somewhere else in the United States or Puerto Rico
one year ago, mark the "No, different house in the United States
or Puerto Rico" box.
15b. Include the house or structure number; street name; street type (for
example, St., Road, Ave.); and the street direction (if a direction such
as "North" is part of the address). For example, print 1239 N. Main St.
or 1239 Main St., N.W., not just 1239 Main. If the person lived in
Puerto Rico, the address should also include the name of the
development or condominium.
If the only known address is a post office box, give a description of the
residence location. For example, print the name of the building where
the person lived, the nearest intersection, the name of a military base
or installation, or the nearest street where the residence was located,
etc. DO NOT GIVE A POST OFFICE BOX NUMBER.
Print the name of the U.S. county or the name of the municipio in
Puerto Rico. If the person lived in Louisiana, print the parish name in
the "Name of U.S. county or municipio in Puerto Rico" space. If
the person lived in Alaska, print the borough or census area name, if
known. If the person lived in New York City and the county name is
not known, print the borough name. If the person lived in an
independent city (not in any county) or in Washington, D.C., leave the
"Name of U.S. county or municipio in Puerto Rico" space blank.
16. Mark the "Yes" or "No" box for each part of question 16.
If the person reports any other type of coverage plan in 16h, specify
the type of coverage or name of the plan in the write-in box. DO NOT
include plans that cover only one type of health care (such as dental
plans) or plans that only cover a person in case of an accident or
disability.
ANSWER PERSON QUESTIONS 18a THROUGH 18c IF THIS PERSON
IS 5 YEARS OLD OR OVER.
18a-18c.
Mark the "Yes" or "No" box to indicate if the person has serious
difficulty with any of the activities listed in parts a, b, and c because
of a physical, mental, or emotional condition.
ANSWER PERSON QUESTIONS 19 THROUGH 48 IF THIS PERSON IS 15
YEARS OLD OR OVER.
20. Mark the "Now married" box for a married person regardless of
whether his or her spouse is living in the household unless they are
separated. If the person’s only marriage was annulled, mark the
"Never married" box.
22. Do not count marriages that ended in annulment.
23. Write the four-digit year when the person last got married, even if
the person is now widowed, divorced, or separated.
ANSWER QUESTION 24 IF THIS PERSON IS FEMALE AND IS 15–50
YEARS OLD.
24. Mark the "Yes" box if the person has given birth to at least one child
born alive in the past 12 months, even if the child died or no longer
lives with the mother. Do not consider miscarriages, or stillborn
children, or any adopted, foster, or stepchildren.
ACS-30(2009) (8-2008)
Page 10
26. For a person with service in the military Reserves, or National Guard,
mark a "Yes" category only if the person has ever been called up for
active duty other than for training. For a person whose only service
was as a civilian employee or civilian volunteer for the Red Cross,
USO, Public Health Service, or War or Defense Department, mark the
"No, never served in the military" box. Count World War II
Merchant Marine service as active duty; DO NOT count other
Merchant Marine service as active duty.
27. Mark as many responses as apply.
28a. Mark the "Yes" box if the person has a Department of Veterans
Affairs (VA) service-connected disability rating.
28b. Mark the "0 percent" box if the person has received a
service-connected disability rating of zero. DO NOT mark the box
showing "0 percent" to indicate no rating.
29a–29b.
Count as work – Mark the "Yes" box if this person performed:
• Work for someone else for wages, salary, piece rate,
commission, tips, or payments "in kind" (for example, food or
lodging received as payment for work performed).
• Work in own business, professional practice, or farm.
• Any work in a family business or farm, paid or not.
• Any part-time work including babysitting, paper routes, etc.
• Active duty in the Armed Forces.
Do not count as work – Mark the "No" box if this person’s
activities were limited to the following:
• Housework or yard work at home.
• Unpaid volunteer work.
• School work done as a student.
• Work done as a resident or inmate of an institution.
30. Include the building or structure number; street name; street type
(for example, St., Road, Ave.); and the street direction (if a direction
such as "North" is part of the address). For example, print 1239 N.
Main St. or 1239 Main St., N.W., not just 1239 Main.
If the only known address is a post office box, give a description of
the work location. For example, print the name of the building or
shopping center where the person works, the nearest intersection,
or the nearest street where the workplace is located, etc. DO NOT
GIVE A POST OFFICE BOX NUMBER.
If the person worked at a military installation or military base that
has no street address, report the name of the military installation or
base, and a description of the work location (such as building
number, building name, nearest street or intersection).
If the person worked at several locations, but reported to the same
location each day to begin work, print the street address of the
location where he or she reported. If the person did not report to
the same location each day to begin work, print the address of the
location where he or she worked most of the time last week.
If the person’s employer operates in more than one location (such as
a grocery store chain or public school system), print the street address
of the location or branch where the person worked. If the street
address of a school is not known, print the name of the school, and a
description of the location (such as nearest street or intersection).
If the person worked on a college or university campus and the street
address of the workplace is not known, print the name of the
building where he or she worked, and a description of the location
(such as nearest street or intersection).
If the person worked in a foreign country or Puerto Rico, Guam, etc.,
print the name of the country on the state or foreign country line.
ACS-30(2009) (8-2008)
Page 11
ANSWER PERSON QUESTION 32 IF YOU MARKED "CAR, TRUCK, OR
VAN" IN QUESTION 31.
32. If the person was driven to work by someone who then drove back
home or to a non-work destination, enter "1" in the box labeled
Person(s).
DO NOT include persons who rode to school or some other non-work
destination in the count of persons who rode in the vehicle.
33. Give the time of day the person usually left home to go to work.
DO NOT give the time that the person usually began his or her work.
If the person usually left home to go to work sometime between
12:00 o’clock midnight and 12:00 o’clock noon, mark "a.m.".
If the person usually left home to go to work sometime between
12:00 o’clock noon and 12:00 o’clock midnight, mark "p.m.".
34. Travel time is from door to door. Enter a one-way commute time
for this person’s usual daily commute from home to work last
week. Include time waiting for public transportation or picking up
passengers in a carpool.
ANSWER PERSON QUESTIONS 35a THROUGH 38 IF THE PERSON DID
NOT WORK LAST WEEK.
35a. Persons are on layoff if they are waiting to be recalled to a job
from which they were temporarily separated for business-related
reasons.
35b. If the person works only during certain seasons or on a day-by-day
basis when work is available, mark the "No" box.
35c. If the person was informed by his or her employer, either formally
or informally, that they will be recalled within the next 6 months,
mark the "Yes" box. Also mark the "Yes" box if the person has
been given, formally or informally, a specific date to return to
work, even if that date is more than 6 months away.
36. Mark the "Yes" box if the person tried to get a job or start a
business or professional practice at any time in the last 4 weeks; for
example, registered at a public or private employment office, went
to a job interview, placed or answered employment ads, or did
anything toward starting a business or professional practice.
37. If the person was expecting to report to a job within 30 days,
mark the "Yes, could have gone to work" box.
Mark the "No, because of own temporary illness" box only if the
person expects to be able to work within 30 days.
If the person could not have gone to work because he or she
was going to school, taking care of children, etc., mark the
"No, because of all other reasons (in school, etc.)" box.
38. Refer to the instructions for questions 29a–29b to determine what to
count as work. Mark the "Over 5 years ago or never worked" box
if the person: (1) never worked at any kind of job or business, either
full or part time, (2) never worked, with or without pay, in a family
business or farm, and (3) never served on active duty in the Armed
Forces.
39a–39b.
Refer to the instructions for questions 29a–29b to determine what to
count as work. Include paid vacation, paid sick leave, and military
service. Count every week in which the person worked at all, even for
an hour.
40. If the hours worked each week varied considerably in the past 12
months, give an approximate average of the hours worked each week.
ACS-30(2009) (8-2008)
Page 12
ANSWER PERSON QUESTIONS 41 THROUGH 46 IF THE PERSON
WORKED IN THE PAST 5 YEARS.
41. Mark the "an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?" box if the person
worked for a cooperative, credit union, mutual insurance company,
or similar organization.
Employees of foreign governments, the United Nations, and other
international organizations should mark the "a Federal
GOVERNMENT employee?" box.
If the person worked at a public school, college or university, mark
the appropriate government category; for example, mark the
"a state GOVERNMENT employee?" box for a state university, or
mark the "a local GOVERNMENT employee (city, county, etc.)?"
box for a county-run community college or a city-run public school.
42. If the person worked for a company, business, or government
agency, print the name of the company, not the name of the
person’s supervisor. If the person worked for an individual or a
business that had no company name, print the name of the
individual this person worked for. If the person worked in his or her
own un-named business, print "self-employed."
43. Print one or more words to describe the business, industry, or
individual employer named in question 42. If there is more than one
activity, describe only the major activity at the place where the
person worked. Enter what is made, what is sold, or what service is
given.
Enter descriptions like the following: hospital, newspaper
publishing, mail order house, auto engine manufacturing, bank.
Do not enter: newspaper, order house, engine.
44. Mark one box to indicate the main type of business or industry
where this person works.
45. Print one or more words to describe the kind of work the
person did. If the person was a trainee, apprentice, or helper,
include that in the description.
Enter descriptions like the following: registered nurse,
personnel manager, supervisor of order department, secretary,
accountant, high school teacher, etc.
Do not enter single words such as: nurse, manager, teacher, etc.
46. Describe the most important activities or duties the person
performed.
Enter descriptions like the following: patient care,
directing hiring policies, supervising order clerks, typing and
filing, reconciling financial records, etc.
ACS-30(2009) (8-2008)
Page 13
ANSWER PERSON QUESTIONS 47 THROUGH 48 IF THIS PERSON IS 15
YEARS OLD OR OVER.
Mark the "Yes" or "No" box for each type of income, and enter the
amount received IN THE PAST 12 MONTHS for each "Yes" response.
If income from any source was received jointly by household members,
report, if possible, the appropriate share for each person; otherwise,
report the whole amount for only one person and mark the "No" box
for the other person.
When reporting income received jointly, DO NOT include the amount for
a person not listed on pages 2, 3, or 4.
DO NOT include the following as income in any item:
•
•
•
•
•
•
Refunds or rebates of any kind
Withdrawals from savings of any kind
Capital gains or losses from the sale of homes, shares of stock, etc.
Inheritances or insurance settlements
Any type of loan
Pay in-kind such as food, free rent
47a. Include wages and salaries before deductions from ALL jobs. Be
sure to include any tips, commissions, or bonuses. Owners of
incorporated businesses should enter their salary here. Military
personnel should include base pay plus cash housing and/or
subsistence allowance, flight pay, uniform allotments, reenlistment
bonuses.
47b. Include NONFARM profit (or loss) from self-employment in sole
proprietorships and partnerships. Exclude profit (or loss) of
incorporated businesses the person owns.
Include FARM profit (or loss) from self-employment in sole
proprietorships and partnerships. Exclude profit (or loss) of
incorporated farm businesses the person owns. Also exclude
amounts from land rented for cash but include amounts from land
rented for shares.
47c. Include interest received or credited to checking and saving
accounts, money market funds, certificates of deposit (CDs), IRAs,
KEOGHs, and government bonds.
Include dividends received, credited, or reinvested from ownership
of stocks or mutual funds.
Include profit (or loss) from royalties and the rental of land,
buildings or real estate, or from roomers or boarders. Income
received by self-employed persons whose primary source of income
is from renting property or from royalties should be included in
question 47b above. Include regular payments from an estate or
trust fund.
47d. Include amounts, before Medicare deductions, of Social Security
and/or Railroad Retirement payments to retired persons, to
dependents of deceased insured workers, and to disabled workers.
47e. Include Supplemental Security Income (SSI) received by elderly,
blind, or disabled persons.
47f. Include any public assistance or welfare payments the person
received from the state or county welfare office. Do not include
assistance received from private charities. Do not include assistance
to pay heating or cooling costs.
ACS-30(2009) (8-2008)
Page 14
47g. Include retirement, survivor or disability benefits received from
companies and unions, federal, state, and local governments, and
the U.S. military. Include regular income from annuities and IRA or
KEOGH retirement plans.
47h. Include Veterans’ (VA) disability compensation and educational
assistance payments (VEAP); unemployment compensation, child
support or alimony; and all other regular payments such as Armed
Forces transfer payments, assistance from private charities, regular
contributions from persons not living in the household.
48.
Add the total entries (subtracting losses) for 47a through 47h for the
PAST 12 MONTHS and enter that number in the space provided. Mark
the "Loss" box if there is a loss. Print the total amount in dollars.
ACS-30(2009) (8-2008)
Page 15
What the Survey Is About -Some Questions and Answers
Why are we taking a survey?
The Census Bureau is conducting the American Community Survey to
provide more timely data than data we typically collect only once every
10 years during the decennial census.
What does the Census Bureau do with the information you provide?
The American Community Survey will be the source of summarized data
that we make available to federal, state, and local governments, and
also to the public. The data will enable your community leaders from
government, business, and non-profit organizations to plan more
effectively.
How was this address selected?
Your address was scientifically selected to represent a cross section of
other households in your community. Households in the sample are
required to complete the survey form. Please return it in the
postage-paid envelope as soon as possible.
Why the Census Bureau Asks Certain
Questions -Here are reasons we ask some of the questions on the survey.
Name
Names help make sure that everyone in a household is included, but that
no one is listed twice.
Value or rent
Government and planning agencies use answers to these questions in
combination with other information to develop housing programs to
meet the needs of people at different economic levels.
Plumbing and Kitchen facilities
This question helps provide information on the quality of housing. The
data are used with other statistics to show how the "level of living"
compares in various areas and how it changes over time.
Place of birth
This question provides information used to study long-term trends about
where people move and to study migration patterns and differences in
growth patterns.
Job
Answers to the questions about the jobs people hold provide information
on the extent and types of employment in different areas of the country.
From this information, communities can develop training programs, and
business and local governments can determine the need for new
employment opportunities.
Income
Income helps determine how well families or persons live. Income
information makes it possible to compare the economic levels of different
areas, and how economic levels for a community change over time.
Funding for many government programs is based on the answers to these
questions.
Education
Responses to the education questions in the survey help to determine the
number of new public schools, education programs, and daycare services
required in a community.
Disability
Questions about disability provide the means to allocate federal funding
for healthcare services and new hospitals in many communities.
Journey to work
Answers to these questions help communities plan road improvements,
develop public transportation services, and design programs to ease traffic
problems.
ACS-30(2009) (8-2008)
Page 16
Frequently Asked
Questions
www.census.gov/acs/www
1-800-354-7271
Si necesita ayuda para completar su cuestionario,
llame sin cargo alguno al: 1-877-833-5625
U.S. Department of Commerce
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACS-10SM(2005)
(5-05)
USCENSUSBUREAU
Helping You Make Informed Decisions
Frequently Asked Questions
What is the American Community Survey?
the American Community Survey questionnaire, you are
your community. Similar data will be produced for
Every 10 years, the U.S. Census Bureau conducts a
helping your community to establish goals, identify
communities across the United States.
census. During Census 2000, the population of the
problems and solutions, and measure the performance of
We may combine your answers with information that
United States was counted, and additional information
programs.
you gave to other agencies to enhance the statistical
was collected to describe the characteristics of the
Communities need data about the well-being of children,
uses of these data. This information will be given the
nation’s population and housing.
families, and the elderly to provide services to them. The
same protections as your survey information. Based on
The next census in 2010 will count the population,
data also are used to decide where to locate new
the information that you provide, you may be asked to
while the American Community Survey collects the
highways, schools, hospitals, and community centers; to
participate in other Census Bureau surveys that are
information about population and housing
show a large corporation that a town has the workforce
voluntary.
characteristics throughout the decade. Based on the
the company needs; and in many other ways.
American Community Survey, the Census Bureau can
provide data about our rapidly changing country more
often than every 10 years.
Do I have to answer the questions on the
American Community Survey?
Will the Census Bureau keep my
information confidential?
Yes. All of the information the Census Bureau collects
Yes, your response to this survey is required by law
for this survey about you and your household is
Why don't you use the information I
provided on my Census 2000 questionnaire?
(Title 13, United States Code, Sections 141 and 193).
confidential by law (Title 13, United States Code,
Title 13, as changed by Title 18, imposes a penalty for
Section 9). By law, every Census Bureau
We need your response even if you completed a
not responding. The survey is approved by the Office of
employee—including the Director as well as every field
Census 2000 questionnaire, because the characteristics
Management and Budget. We estimate this survey will
representative—has taken an oath and is subject to a
of your household may have changed since Census
take about 38 minutes to complete.
jail term, a fine, or both if he or she discloses ANY
information that could identify you or your household.
2000. As we move further away from 2000, information
provided in Census 2000 becomes outdated.
How will the Census Bureau use the
information that I provide?
How do I benefit by answering the
American Community Survey?
The Census Bureau can use the information you provide
for statistical purposes only and cannot publish or release
Where can I find more information about
the American Community Survey or get
assistance?
The American Community Survey provides up-to-date
information that would identify you and your household.
You may visit our Web site www.census.gov/acs/www,
information for the nation, states, cities, counties,
Your information will be used in combination with
or call 1-800-354-7271 if you need assistance or more
metropolitan areas, and communities. By responding to
information from other households to produce data for
information.
13198015
DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
Please complete this form and return
it as soon as possible after receiving
it in the mail.
This form asks for information about
the people who are living or staying at
the address on the mailing label and
about the house, apartment, or mobile
home located at the address on the
mailing label.
Start Here
➜
Please print today’s date.
Year
Month Day
➜
Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name
First Name
MI
Area Code + Number
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
—
➜
How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people
➜
Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede pedir un cuestionario en
español o completar su entrevista por teléfono
con un entrevistador que habla español.
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/
USCENSUSBUREAU
ACS-1(2008)KFI
FORM
(07-31-2007)
OMB No. 0607-0810
§.4q0¤
ACS-1(2008)KFI, Page 1, Base (Black)
ACS-1(2008)KFI, Page 1, Green Pantone 354 (20 and 40%)
13198023
Person 1
Person 2
1 What is Person 2’s name?
(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1?
X
3
Person 1
4
Female
Month
Day
Year of birth
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
6 What is Person 2’s race? Mark (X) one or more boxes.
What is Person 1’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Some other race – Print race.
2
Roomer or boarder
Stepson or stepdaughter
Age (in years)
Question 6 about race. For this survey, Hispanic origins are not races.
6
Adopted son or daughter
Male
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Other relative
3 What is Person 2’s sex? Mark (X) ONE box.
What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Son-in-law or daughter-in-law
Biological son or daughter
Parent-in-law
What is Person 1’s sex? Mark (X) ONE box.
Male
Husband or wife
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Some other race – Print race.
§.4q8¤
ACS-1(2008)KFI, Page 2, Base (Black)
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13198031
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Other relative
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Female
Male
What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
Question 6 about race. For this survey, Hispanic origins are not races.
Female
4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
6
2 How is this person related to Person 1? Mark (X) ONE box.
Son-in-law or daughter-in-law
Age (in years)
5
MI
Biological son or daughter
Male
4
First Name
Husband or wife
Parent-in-law
3
Last Name (Please print)
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 4 of Hispanic, Latino, or Spanish origin?
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
6 What is Person 4’s race? Mark (X) one or more boxes.
What is Person 3’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Some other race – Print race.
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Some other race – Print race.
§.4q@¤
ACS-1(2008)KFI, Page 3, Base (Black)
3
ACS-1(2008)KFI, Page 3, Green Pantone 354 (20 and 40%)
13198049
Person 5
1
➜
What is Person 5’s name?
Last Name (Please print)
First Name
MI
If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.
Person 6
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
3
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Sex
Female
Month
Female
Day
Last Name (Please print)
First Name
MI
Year of birth
Sex
Male
Female
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Age (in years)
Person 8
What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Male
Is Person 5 of Hispanic, Latino, or Spanish origin?
Age (in years)
Person 9
Last Name (Please print)
First Name
MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Sex
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Male
Female
Person 10
Last Name (Please print)
6
Age (in years)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Male
Female
Person 11
Last Name (Please print)
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Sex
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Age (in years)
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race.
Sex
4
Male
Female
Age (in years)
§.4qR¤
ACS-1(2008)KFI, Page 4, Base (Black)
MI
ACS-1(2008)KFI, Page 4, Green Pantone 354 (20 and 40%)
MI
13198056
Housing
➜
1
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
8 Does this house, apartment, or mobile
Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.
home have –
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.
a. hot and cold running water?
4 How many acres is this house or
c. a bathtub or shower?
mobile home on?
Less than 1 acre ➔ SKIP to question 6
d. a sink with a faucet?
1 to 9.9 acres
e. a stove or range?
10 or more acres
f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.
5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
None
9 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
None
$5,000 to $9,999
1
$10,000 or more
2
About when was this building first built?
2000 or later – Specify year
3
6 Is there a business (such as a store or
4
barber shop) or a medical office on
this property?
5
6 or more
Yes
1990 to 1999
No
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
3
No
b. a flush toilet?
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
2
Yes
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
10 Which FUEL is used MOST for heating this
7 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms
house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
Year
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
No fuel used
Number of bedrooms
§.4qY¤
ACS-1(2008)KFI, Page 5, Base (Black)
5
ACS-1(2008)KFI, Page 5, Green Pantone 354 (10, 20, 40 and 50%)
13198064
Housing (continued)
11 a. LAST MONTH, what was the cost
12 IN THE PAST 12 MONTHS, did anyone in
of electricity for this house,
apartment, or mobile home?
this household receive Food Stamps or
a Food Stamp benefit card?
Last month’s cost – Dollars
$
Yes
No
.00
,
OR
Included in rent or condominium fee
part of a condominium?
16 About how much do you think this
Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
Last month’s cost – Dollars
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?
Amount – Dollars
$
Monthly amount – Dollars
.00
,
Answer questions 16 – 20 if you or
someone else in this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E on
the next page.
13 Is this house, apartment, or mobile home
No charge or electricity not used
$
C
$
OR
.00
,
Included in rent or condominium fee
17 What are the annual real estate taxes on
THIS property?
OR
Included in electricity payment
entered above
No charge or gas not used
.00
,
,
Annual amount – Dollars
None
$
No
.00
,
OR
c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
14 Is this house, apartment, or mobile home –
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Past 12 months’ cost – Dollars
$
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
.00
,
OR
Rented?
No charge
18 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
Occupied without payment of
rent? ➔ SKIP to C
Included in rent or condominium fee
d. IN THE PAST 12 MONTHS, what was the
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
home? If you have lived here less than 12
months, estimate the cost.
None
Mark (X) ONE box.
.00
,
OR
None
B
Answer questions 15a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 16.
Past 12 months’ cost – Dollars
$
.00
,
15 a. What is the monthly rent for this
house, apartment, or mobile home?
OR
Monthly amount – Dollars
Included in rent or condominium fee
No charge or these fuels not used
$
,
.00
b. Does the monthly rent include any
meals?
Yes
No
6
§.4qa¤
ACS-1(2008)KFI, Page 6, Base (Black)
ACS-1(2008)KFI, Page 6, Green Pantone 354 (10, 20, 40 and 50%)
13198072
Housing (continued)
19 a. Do you or any member of this
20 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
E
Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home
equity loan
No ➔ SKIP to D
No ➔ SKIP to question 20a
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?
Monthly amount – Dollars
Monthly amount – Dollars
$
,
.00
$
OR
OR
No regular payment required ➔ SKIP to
question 20a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
.00
,
No regular payment required
D
Answer question 21 if this is a MOBILE
HOME. Otherwise, SKIP to E .
21 What are the total annual costs for
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
Annual costs – Dollars
$
,
.00
§.4qi¤
ACS-1(2008)KFI, Page 7, Base (Black)
7
ACS-1(2008)KFI, Page 7, Green Pantone 354 (10, 20, 40 and 50%)
13198080
Person 1
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 1 from Page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
14 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
Address (Number and street name)
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
8
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
No, not a U.S. citizen
When did this person come to live in the
United States? Print numbers in boxes.
Year
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
13 a. Does this person speak a language other than
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
Yes No
a. Insurance through a current or
former employer or union (of this
person or another family member)
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
ZIP Code
15 Is this person CURRENTLY covered by any of the
12 What is this person’s ancestry or ethnic origin?
person attended school or college? Include only
Yes, public school, public college
Name of U.S. state or
Puerto Rico
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has this
No, has not attended in the last 3 months ➔
SKIP to question 11
Name of U.S. county or municipio in
Puerto Rico
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
Name of city, town, or post office
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
8
Well
Not well
Not at all
§.4qq¤
ACS-1(2008)KFI, Page 8, Base (Black)
ACS-1(2008)KFI, Page 8, Green Pantone 354 (20, 40, 50 and 100%)
13198098
Person 1 (continued)
20 In the PAST 12 MONTHS did this person get –
Yes
16 a. Is this person deaf or does he/she have
25 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
No
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
a. Married?
serious difficulty hearing?
Yes
b. Widowed?
Yes, now on active duty
No
c. Divorced?
Yes, on active duty during
the last 12 months, but not now
b. Is this person blind or does he/she have
21 How many times has this person been married?
serious difficulty seeing even when wearing
glasses?
Once
F
Yes
Two times
No
Three or more times
Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
22 In what year did this person last get married?
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 27a
No, never served in the military ➔ SKIP to
question 28a
26 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Year
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
17 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
H
Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
23 Has this person given birth to any children in
February 1955 to February 1961
the past 12 months?
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
November 1941 or earlier
c. Does this person have difficulty dressing or
bathing?
Yes
No
24 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
27 a. Does this person have a VA service-connected
Yes
No ➔ SKIP to question 25
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
G
Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
18 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
Yes
No
19 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
b. Is this grandparent currently responsible for
most of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this house or
apartment?
b. What is this person’s service-connected
disability rating?
Yes
0 percent
No ➔ SKIP to question 25
10 or 20 percent
30 or 40 percent
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
50 or 60 percent
70 percent or higher
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Never married ➔ SKIP to H
§.4q¥¤
ACS-1(2008)KFI, Page 9, Base (Black)
9
ACS-1(2008)KFI, Page 9, Green Pantone 354 (10, 20, 40 and 50%)
13198106
Person 1 (continued)
I
28 a. LAST WEEK, did this person work for pay
Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.
at a job (or business)?
35 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
Yes ➔ SKIP to question 29
No – Did not work (or retired)
31 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
36 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did this person work LAST
32 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
37 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to K
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
33 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 46
38 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 39
c. Is the work location inside the limits of that
city or town?
J
Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
34 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 34c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
13 weeks or less
39 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
30 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 36
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 38a
Ferryboat
Other method
Taxicab
10
§.4r’¤
ACS-1(2008)KFI, Page 10, Base (Black)
ACS-1(2008)KFI, Page 10, Green Pantone 354 (10, 20, 40 and 50%)
13198114
Person 1 (continued)
K
Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.
40 – 45 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
44 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
41 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
46 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
45 What were this person’s most important
40 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
47 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 46a
42 What kind of business or industry was this?
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
43 Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 2 on the
next page. If only 1 person is listed on page 2,
SKIP to page 28 for mailing instructions.
§.4r/¤
ACS-1(2008)KFI, Page 11, Base (Black)
Loss
11
ACS-1(2008)KFI, Page 11, Green Pantone 354 (10, 20, 40 and 50%)
13198122
Person 2
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
14 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
Address (Number and street name)
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
8
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
No, not a U.S. citizen
When did this person come to live in the
United States? Print numbers in boxes.
Year
ZIP Code
15 Is this person CURRENTLY covered by any of the
12 What is this person’s ancestry or ethnic origin?
person attended school or college? Include only
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Yes, public school, public college
Name of U.S. state or
Puerto Rico
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has this
No, has not attended in the last 3 months ➔
SKIP to question 11
Name of U.S. county or municipio in
Puerto Rico
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
Name of city, town, or post office
13 a. Does this person speak a language other than
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
Yes No
a. Insurance through a current or
former employer or union (of this
person or another family member)
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
12
Well
Not well
Not at all
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13198130
Person 2 (continued)
20 In the PAST 12 MONTHS did this person get –
Yes
16 a. Is this person deaf or does he/she have
25 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
No
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
a. Married?
serious difficulty hearing?
Yes
b. Widowed?
Yes, now on active duty
No
c. Divorced?
Yes, on active duty during
the last 12 months, but not now
b. Is this person blind or does he/she have
21 How many times has this person been married?
serious difficulty seeing even when wearing
glasses?
Once
F
Yes
Two times
No
Three or more times
Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
22 In what year did this person last get married?
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 27a
No, never served in the military ➔ SKIP to
question 28a
26 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Year
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
17 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
H
Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
23 Has this person given birth to any children in
February 1955 to February 1961
the past 12 months?
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
November 1941 or earlier
c. Does this person have difficulty dressing or
bathing?
Yes
No
24 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
27 a. Does this person have a VA service-connected
Yes
No ➔ SKIP to question 25
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
G
Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
18 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
Yes
No
19 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
b. Is this grandparent currently responsible for
most of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this house or
apartment?
b. What is this person’s service-connected
disability rating?
Yes
0 percent
No ➔ SKIP to question 25
10 or 20 percent
30 or 40 percent
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
50 or 60 percent
70 percent or higher
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Never married ➔ SKIP to H
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Person 2 (continued)
I
28 a. LAST WEEK, did this person work for pay
Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.
at a job (or business)?
35 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
Yes ➔ SKIP to question 29
No – Did not work (or retired)
31 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
36 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did this person work LAST
32 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
37 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to K
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
33 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 46
38 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 39
c. Is the work location inside the limits of that
city or town?
J
Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
34 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 34c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
13 weeks or less
39 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
30 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 36
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 38a
Ferryboat
Other method
Taxicab
14
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Person 2 (continued)
K
Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.
40 – 45 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
44 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
41 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
46 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
45 What were this person’s most important
40 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
47 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 46a
42 What kind of business or industry was this?
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
43 Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 3 on the
next page. If only 2 people are listed on page 2,
SKIP to page 28 for mailing instructions.
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13198163
Person 3
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
14 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
Address (Number and street name)
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
8
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
No, not a U.S. citizen
When did this person come to live in the
United States? Print numbers in boxes.
Year
ZIP Code
15 Is this person CURRENTLY covered by any of the
12 What is this person’s ancestry or ethnic origin?
person attended school or college? Include only
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Yes, public school, public college
Name of U.S. state or
Puerto Rico
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has this
No, has not attended in the last 3 months ➔
SKIP to question 11
Name of U.S. county or municipio in
Puerto Rico
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
Name of city, town, or post office
13 a. Does this person speak a language other than
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
Yes No
a. Insurance through a current or
former employer or union (of this
person or another family member)
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
16
Well
Not well
Not at all
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13198171
Person 3 (continued)
20 In the PAST 12 MONTHS did this person get –
Yes
16 a. Is this person deaf or does he/she have
25 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
No
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
a. Married?
serious difficulty hearing?
Yes
b. Widowed?
Yes, now on active duty
No
c. Divorced?
Yes, on active duty during
the last 12 months, but not now
b. Is this person blind or does he/she have
21 How many times has this person been married?
serious difficulty seeing even when wearing
glasses?
Once
F
Yes
Two times
No
Three or more times
Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
22 In what year did this person last get married?
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 27a
No, never served in the military ➔ SKIP to
question 28a
26 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Year
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
17 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
H
Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
23 Has this person given birth to any children in
February 1955 to February 1961
the past 12 months?
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
November 1941 or earlier
c. Does this person have difficulty dressing or
bathing?
Yes
No
24 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
27 a. Does this person have a VA service-connected
Yes
No ➔ SKIP to question 25
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
G
Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
18 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
Yes
No
19 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
b. Is this grandparent currently responsible for
most of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this house or
apartment?
b. What is this person’s service-connected
disability rating?
Yes
0 percent
No ➔ SKIP to question 25
10 or 20 percent
30 or 40 percent
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
50 or 60 percent
70 percent or higher
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Never married ➔ SKIP to H
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13198189
Person 3 (continued)
I
28 a. LAST WEEK, did this person work for pay
Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.
at a job (or business)?
35 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
Yes ➔ SKIP to question 29
No – Did not work (or retired)
31 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
36 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did this person work LAST
32 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
37 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to K
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
33 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 46
38 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 39
c. Is the work location inside the limits of that
city or town?
J
Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
34 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 34c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
13 weeks or less
39 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
30 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 36
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 38a
Ferryboat
Other method
Taxicab
18
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13198197
Person 3 (continued)
K
Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.
40 – 45 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
44 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
41 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
46 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
45 What were this person’s most important
40 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
47 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 46a
42 What kind of business or industry was this?
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
43 Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 4 on the
next page. If only 3 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.
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13198205
Person 4
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 4 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
14 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
Address (Number and street name)
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
8
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
No, not a U.S. citizen
When did this person come to live in the
United States? Print numbers in boxes.
Year
ZIP Code
15 Is this person CURRENTLY covered by any of the
12 What is this person’s ancestry or ethnic origin?
person attended school or college? Include only
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Yes, public school, public college
Name of U.S. state or
Puerto Rico
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has this
No, has not attended in the last 3 months ➔
SKIP to question 11
Name of U.S. county or municipio in
Puerto Rico
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
Name of city, town, or post office
13 a. Does this person speak a language other than
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
Yes No
a. Insurance through a current or
former employer or union (of this
person or another family member)
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
20
Well
Not well
Not at all
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13198213
Person 4 (continued)
20 In the PAST 12 MONTHS did this person get –
Yes
16 a. Is this person deaf or does he/she have
25 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
No
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
a. Married?
serious difficulty hearing?
Yes
b. Widowed?
Yes, now on active duty
No
c. Divorced?
Yes, on active duty during
the last 12 months, but not now
b. Is this person blind or does he/she have
21 How many times has this person been married?
serious difficulty seeing even when wearing
glasses?
Once
F
Yes
Two times
No
Three or more times
Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
22 In what year did this person last get married?
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 27a
No, never served in the military ➔ SKIP to
question 28a
26 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Year
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
17 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
H
Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
23 Has this person given birth to any children in
February 1955 to February 1961
the past 12 months?
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
November 1941 or earlier
c. Does this person have difficulty dressing or
bathing?
Yes
No
24 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
27 a. Does this person have a VA service-connected
Yes
No ➔ SKIP to question 25
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
G
Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
18 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
Yes
No
19 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
b. Is this grandparent currently responsible for
most of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this house or
apartment?
b. What is this person’s service-connected
disability rating?
Yes
0 percent
No ➔ SKIP to question 25
10 or 20 percent
30 or 40 percent
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
50 or 60 percent
70 percent or higher
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Never married ➔ SKIP to H
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13198221
Person 4 (continued)
I
28 a. LAST WEEK, did this person work for pay
Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.
at a job (or business)?
35 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
Yes ➔ SKIP to question 29
No – Did not work (or retired)
31 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
36 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did this person work LAST
32 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
37 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to K
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
33 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 46
38 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 39
c. Is the work location inside the limits of that
city or town?
J
Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
34 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 34c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
13 weeks or less
39 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
30 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 36
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 38a
Ferryboat
Other method
Taxicab
22
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13198239
Person 4 (continued)
K
Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.
40 – 45 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
44 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
41 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
46 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
45 What were this person’s most important
40 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
47 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 46a
42 What kind of business or industry was this?
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
43 Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 5 on the
next page. If only 4 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.
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Person 5
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 5 from page 4,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
14 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 15
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12th grade – NO DIPLOMA
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
Address (Number and street name)
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
8
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
No, not a U.S. citizen
When did this person come to live in the
United States? Print numbers in boxes.
Year
ZIP Code
15 Is this person CURRENTLY covered by any of the
12 What is this person’s ancestry or ethnic origin?
person attended school or college? Include only
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Yes, public school, public college
Name of U.S. state or
Puerto Rico
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has this
No, has not attended in the last 3 months ➔
SKIP to question 11
Name of U.S. county or municipio in
Puerto Rico
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
Name of city, town, or post office
13 a. Does this person speak a language other than
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
English at home?
Yes
No ➔ SKIP to question 14a
b. What is this language?
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
Yes No
a. Insurance through a current or
former employer or union (of this
person or another family member)
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Very well
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
24
Well
Not well
Not at all
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Person 5 (continued)
20 In the PAST 12 MONTHS did this person get –
Yes
16 a. Is this person deaf or does he/she have
25 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
No
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
a. Married?
serious difficulty hearing?
Yes
b. Widowed?
Yes, now on active duty
No
c. Divorced?
Yes, on active duty during
the last 12 months, but not now
b. Is this person blind or does he/she have
21 How many times has this person been married?
serious difficulty seeing even when wearing
glasses?
Once
F
Yes
Two times
No
Three or more times
Answer question 17a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
22 In what year did this person last get married?
Yes, on active duty in the past, but not
during the last 12 months
No, training for Reserves or National Guard
only ➔ SKIP to question 27a
No, never served in the military ➔ SKIP to
question 28a
26 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
Year
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
17 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
H
Answer question 23 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 24a.
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
23 Has this person given birth to any children in
February 1955 to February 1961
the past 12 months?
Korean War (July 1950 to January 1955)
Yes
January 1947 to June 1950
No
World War II (December 1941 to December 1946)
November 1941 or earlier
c. Does this person have difficulty dressing or
bathing?
Yes
No
24 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
27 a. Does this person have a VA service-connected
Yes
No ➔ SKIP to question 25
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 28a
G
Answer question 18 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
18 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?
Yes
No
19 What is this person’s marital status?
Now married
Widowed
Divorced
Separated
b. Is this grandparent currently responsible for
most of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this house or
apartment?
b. What is this person’s service-connected
disability rating?
Yes
0 percent
No ➔ SKIP to question 25
10 or 20 percent
30 or 40 percent
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
50 or 60 percent
70 percent or higher
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Never married ➔ SKIP to H
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13198262
Person 5 (continued)
I
28 a. LAST WEEK, did this person work for pay
Answer question 31 if you marked "Car,
truck, or van" in question 30. Otherwise,
SKIP to question 32.
at a job (or business)?
35 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
Yes ➔ SKIP to question 29
No – Did not work (or retired)
31 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
36 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did this person work LAST
32 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
37 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to K
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
33 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 46
38 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 39
c. Is the work location inside the limits of that
city or town?
J
Answer questions 34 – 37 if this person
did NOT work last week. Otherwise,
SKIP to question 38a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
34 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 34c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
13 weeks or less
39 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
30 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 36
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 38a
Ferryboat
Other method
Taxicab
26
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13198270
Person 5 (continued)
K
Answer questions 40 – 45 if this person
worked in the past 5 years. Otherwise,
SKIP to question 46.
40 – 45 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
44 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
41 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
46 INCOME IN THE PAST 12 MONTHS.
an employee of a PRIVATE NOT FOR PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
45 What were this person’s most important
40 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
47 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 46a
42 What kind of business or industry was this?
to 46h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
43 Is this mainly – Mark (X) one box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Now continue with the mailing instructions
on page 28.
§.4sg¤
ACS-1(2008)KFI, Page 27, Base (Black)
Loss
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13198288
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ Then...
• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.
For Census Bureau Use
POP
EDIT
EDIT CLERK
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 38 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2008)KFI (07-31-2007)
28
§.4sy¤
ACS-1(2008)KFI, Page 28, Base (Black)
ACS-1(2008)KFI, Page 28, Green Pantone 354 (20, 40 and 50%)
C
AN EQUAL OPPORTUNITY EMPLOYER
OFFICIAL BUSINESS
Penalty for Private Use $300
5385-47(2008) (10-2007)
BUSINESS REPLY MAIL
FIRST-CLASS MAIL
PERMIT NO. 16081
WASHINGTON DC
POSTAGE WILL BE PAID BY THE U.S. CENSUS BUREAU
DIRECTOR
U.S. CENSUS BUREAU
PO BOX 5240
JEFFERSONVILLE IN 47199-5240
|4719952409|
4719952409
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
| File Type | application/pdf |
| File Modified | 2008-09-18 |
| File Created | 2008-09-18 |