The American Community Survey

ATTACHMENT H

Questions for the American Community Survey

Computer-assisted Telephone Interviewing (CATI) Failed Edit Follow Up (FEFU)

Paper Questionnaire Item Number: Roster

FEFU Screen Name: USTATVER

On (RDATE), was there anyone living or staying at this address for more than two months?

***NOTE: RDATE stands for the Response Date, or the estimated date the respondent completed the questionnaire.

FEFU Screen Name: CJIC2

On (RDATE) was this housing unit....?

 1. Temporarily Occupied

 2. Vacant

 3. a Group Quarters

 4. for Commercial Use Only

FEFU Screen Name: CJIC3

On (RDATE) was this housing unit....?

❍ 1. For rent

❍ 2. Rented, not occupied

❍ 3. For sale only

❍ 4. Sold, not occupied

❍ 5. For seasonal, recreational or occasional use

❍ 6. For migrant workers

❍ 7. Other vacant

FEFU Screen Name: CoverageP

[I’d like to make sure that we’ve included everyone. I see that the household size (fill 2: <was not indicated> / <was indicated as CURRENTSTATUS.CPER>) but we have data for <CURRENTSTATUS.ActualPop> persons.]

I have listed: (<READ ROSTER >) How many people were here for more than two months on (<RDATE>)?

01 Sally P Smith

02 John D Smith

03 Brandon C Smith

04

05

06

07

.

.

.

20

FEFU Screen Name: LN_PG2, FN_PG2, MI_PG2

(Last/First) Name (MI)

(INCLUDE everyone living or staying here for more than two months.

INCLUDE anyone else staying here who does not have another place to stay even if they are here for two months or less.

DO NOT INCLUDE anyone who is living somewhere else for more than two months, such as a college student living away.)

Paper Questionnaire Item Number: Demographic 3

FEFU Screen Name: SEX

(Are you /Is <Name>) male or female?

 1. Male

 2. Female

Paper Questionnaire Item Number: Demographic 4

FEFU Screen Name: P2DOB

What is (<Name>’s/your) date of birth?

♢ Enter the month/day/4-digit year

FEFU Screen Name: AGEP

So that makes (<Name>/you) <AGE> as of <RDATE>?

FEFU Screen Name: AGEVER

The birth date provided on the questionnaire makes (<Name>/you) <AGEP>, but the age given was <InputAge> as of <RDATE>.

Which is correct?

FEFU Screen Name: AGEASK

How old (are you/is <Name>)?

Paper Questionnaire Item Number: Demographic 5

FEFU Screen Name: HISW

What is that origin?

(For example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.)

Paper Questionnaire Item Number: Demographic 6

FEFU Screen Name: RAC

What is (<Name>’s/your) race? You may choose one or more races. For this survey, Hispanic origins are not races.
 11. White  12. Black, African Am., or Negro  13. American Indian or Alaska Native  14. Asian Indian  15. Chinese	 16. Filipino  17. Japanese  18. Korean  19. Vietnamese  20. Other Asian (For example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.)	 21. Native Hawaiian  22. Guamanian or Chamorro  23. Samoan  24. Other Pacific Islander (For example, Fijian, Tongan, and so on.)  25. Some other race

FEFU Screen Name: RCW1

What is (his/her/your) enrolled or principal tribe? You may list one or more tribes.

FEFU Screen Name: RCW2

If <24>:

What is that other Pacific Islander Group?

(For example, Fijian, Tongan, and so on.)

If <25> or EMPTY:

What is <his/her/your> other race group?

If <24> and <25>:

What is <his/her/your> other race group, and other Pacific Islander Group?

(For example, Fijian, Tongan, and so on.)

FEFU Screen Name: RCW3

What is that other Asian group?

(For example: Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.)

Paper Questionnaire Item Number: Housing 2

FEFU Screen Name: YBL

About when was this <mobile home/house/apartment/unit> first built?

(If you do not know exact year, give your best estimate.)

 1. 2000 or later

 2. 1990-1999

 3. 1980-1989

 4. 1970-1979

 5. 1960-1969

 6. 1950-1959

 7. 1940-1949

 8. 1939 or earlier

FEFU Screen Name: YBLW

(What year was this <mobile home/house/apartment/unit> built?)

Paper Questionnaire Item Number: Housing 3

FEFU Screen Name: MVM

When did (you/<HHOLDER>) move into this <mobile home/ house/ apartment/ unit>?

♢ Select month

FEFU Screen Name: MVY

When did (you/<HHOLDER>) move into this <mobile home/ house/ apartment/ unit>?

♢ Enter the year the household moved into this (mobile home/ house/ apartment/ unit).

Paper Questionnaire Item Number: Housing 7b

FEFU Screen Name: BDS

How many of these rooms are bedrooms?

Count as bedrooms those rooms you would list if this <mobile home/ house/ apartment/ unit> were for sale or rent. If this is an efficiency/studio apartment, you would not count any bedrooms.

Paper Questionnaire Item Number: Housing 11a

FEFU Screen Name: ELE

LAST MONTH, what was the cost of electricity for this <mobile home/ house/ apartment/ unit>?

FEFU Screen Name: ELEX

Was the electricity -- Included in rent or condominium fee, or No charge for electricity or electricity not used?

 1. Included in rent or condominium fee

 2. No charge or electricity not used

Paper Questionnaire Item Number: Housing 11b

FEFU Screen Name: GAS

LAST MONTH, what was the cost of gas for this <mobile home/ house/ apartment/ unit>?

FEFU Screen Name: GASX

Was the gas -- Included in rent or condominium fee, Included in electricity payment, or No charge or gas not used?

 1. Included in rent or condominium fee

 2. Included in electricity payment

 3. No charge or gas not used

Paper Questionnaire Item Number: Housing 11c

FEFU Screen Name: WAT

IN THE PAST 12 MONTHS, what was the cost of water and sewer for this <mobile home/ house/ apartment/ unit>?

FEFU Screen Name: WATX

Was the water and sewer -- Included in rent or condominium fee, or

No charge for water or sewer?

 1. Included in rent or condominium fee

 2. No charge

Paper Questionnaire Item Number: Housing 11d

FEFU Screen Name: FUL

IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this <mobile home/house/apartment/unit>?

FEFU Screen Name: FULX

Were the Other Fuel costs -- Included in rent or condominium fee, or No charge or these fuels are not used?

 1. Included in rent or condominium fee

 2. No charge or these fuels not used

Paper Questionnaire Item Number: Housing 15a

FEFU Screen Name: RenterRN

What is the monthly rent?

Paper Questionnaire Item Number: Person 7

FEFU Screen Name: PBX1

Where (was <Name>/were you) born?

 1. In the United States

 2. Outside the United States

FEFU Screen Name: PBW2

In what state was that?

FEFU Screen Name: PBW3

In what foreign country was that?

Paper Questionnaire Item Number: Person 8

FEFU Screen Name: CIT

(Is <Name>/Are you) a CITIZEN of the United States?

(How was the citizenship obtained?)

 1. Yes, born in the United States

 2. Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands or Northern Marianas

 3. Yes, born abroad of U.S. citizen parent or parents

 4. Yes, a U.S. citizen by naturalization

 5. No, not a U.S. citizen

FEFU Screen Name: CITW

In what year did (<Name>/you) become a naturalized citizen of the United States?

Paper Questionnaire Item Number: Person 10b

FEFU Screen Name: SCHG

What grade or level (was <he/she>/ were you) attending?

 1. Nursery school, preschool

 2. Kindergarten

 3. Grade 1 through 12

 4. College undergraduate years (freshman to senior)

 5. Graduate or professional school beyond a bachelor’s degree (for example: MA

or PhD program, or medical or law school)

FEFU Screen Name: SCHGW

(What grade (was <he/she>/ were you) attending?)

Paper Questionnaire Item Number: Person 11

FEFU Screen Name: SCHL

What is the highest degree or level of school (<Name> has/you have) COMPLETED?

 1. No schooling completed

 2. Nursery school

 3. Kindergarten

 4. Grade 1 through 11

 5. 12^th grade - NO DIPLOMA

 6. Regular high school diploma

 7. GED or alternative credential

 8. Some college credit, but less than 1 year of college credit

 9. 1 or more years of college credit, no degree

10. Associate’s degree (for example: AA, AS)

11. Bachelor’s degree (for example: BA, BS)

12. Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

13. Professional degree beyond a bachelor’s degree (for example: MD, DDS,

DVM, LLB, JD)

14. Doctorate degree (for example: PhD, EdD)

FEFU Screen Name: SCHLW

(What is the highest grade (<he/she> has/you have) COMPLETED?)

Paper Questionnaire Item Number: Person 14a and 14b

FEFU Screen Name: MIG

Did (<Name>/you) live in this <mobile home/ house/ apartment/ unit> 1 year ago?

 1. Person is under 1 year old

 2. Yes, this house

 3. No, outside the United States and Puerto Rico

 4. No, different house in the United States or Puerto Rico

FEFU Screen Name: MGW1

What was the foreign country?

FEFU Screen Name: MGW2

Where did (<Name>/you) live 1 year ago? What was the street address?

FEFU Screen Name: MGW3

What was the city, town, or post office?

FEFU Screen Name: MGW4

What was the U.S. county or municipio in Puerto Rico?

FEFU Screen Name: MGW5

What was the U.S. state, or was that in Puerto Rico?

FEFU Screen Name: MGW6

What was the ZIP code?

Paper Questionnaire Item Number: Person 15

FEFU Screen Name: HINS1

(Are you/Is <Name>) currently covered by health insurance through a current or former employer or union of (yours/<yours/him/her> or another family member)?

FEFU Screen Name: HINS2

(Are you/Is <Name>) currently covered by health insurance purchased directly from an insurance company by (you/<you/him/her> or another family member)?

FEFU Screen Name: HINS3

(Are you/Is <Name>) currently covered by Medicare, for people age 65 or older or people with certain disabilities?

FEFU Screen Name: HINS4

(Are you/Is <Name>) currently covered by Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?

FEFU Screen Name: HINS5

(Are you/Is <Name>) currently covered by TRICARE or other military health care?

FEFU Screen Name: HINS6

(Are you/Is <Name>) currently covered through the VA or have you ever used or enrolled for VA health care?

FEFU Screen Name: HINS7

(Are you/Is <Name>) currently covered through the Indian Health Service?

FEFU Screen Name: HINS8

(Are you/Is <Name>) currently covered by any other health insurance or health coverage plan?

FEFU Screen Name: HINSW

What is the name of the health care plan?

Paper Questionnaire Item Number: Person 19

FEFU Screen Name: MAR

(Is <Name>/Are you) married, widowed, divorced, separated, or never married?

 1. Now married

 2. Widowed

 3. Divorced

 4. Separated

 5. Never married

Paper Questionnaire Item Number: Person 20

FEFU Screen Name: MARHM

In the past 12 months, did (<Name>/you) get married?

FEFU Screen Name: MARHW

In the past 12 months, did (<Name>/you) become a (<widow/widower>)?

FEFU Screen Name: MARHD

In the past 12 months, did (<Name>/you) get divorced?

Paper Questionnaire Item Number: Person 21

FEFU Screen Name: MARHT

How many times (has <Name>/have you) been married? Is that --

 1. Once

 2. Two times

 3. Three or more times

Paper Questionnaire Item Number: Person 27b

FEFU Screen Name: DRAT

What is (<Name>’s/your) service-connected disability rating? Is it:

 1. 0 percent

 2. 10 or 20 percent

 3. 30 or 40 percent

 4. 50 or 60 percent

 5. 70 percent or higher

Paper Questionnaire Item Number: Person 28a

FEFU Screen Name: WRK

During the week of (<RDATE-7>), did (<Name>/you) do any work for pay at a job or business?

(Include any work even if (<he/she>/you) worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or (was/were) on active duty in the Armed Forces.)

 1. Yes

 2. No – Did not work (or retired)

Paper Questionnaire Item Number: Person 28b

FEFU Screen Name: WRKJ

During the week of (<RDATE-7>), did (<Name>/you) do ANY work for pay, even for as little as one hour?

Paper Questionnaire Item Number: Person 29a

FEFU Screen Name:

During the week of (<RDATE-7>), at what location did (<Name>/you) work?

(What is the street number and street name of the location?)

Paper Questionnaire Item Number: Person 29b

FEFU Screen Name: PWW2

What is the name of the city or town where (<Name>/you) worked during the week of (<RDATE-7>)?

Paper Questionnaire Item Number: Person 29d

FEFU Screen Name: PWW4

What is the name of the county where (<Name>/you) worked during the week of (<RDATE-7>)?

Paper Questionnaire Item Number: Person 29e

FEFU Screen Name: PWW5

What is the state or foreign country where (<Name>/you) worked during the week of (<RDATE-7>)?

Paper Questionnaire Item Number: Person 29f

FEFU Screen Name: PWW6

What is the ZIP Code where (<Name>/you) worked during the week of (<RDATE-7>)?

Paper Questionnaire Item Number: Person 30

FEFU Screen Name: JWTR

During the week of (<RDATE-7>) how did (<Name>/ you) USUALLY get to work?

 1. Car, truck, or van  5. Railroad  9. Bicycle

 2. Bus or trolley bus  6. Ferryboat  10. Walked

 3. Streetcar or trolley car  7. Taxicab  11. Worked at home

 4. Subway or elevated  8. Motorcycle  12. Other method

Paper Questionnaire Item Number: Person 31

FEFU Screen Name: JWRI

During the week of (<RDATE-7>), how many people, including (<Name>/you) usually rode to work in the car, truck, or van?

Paper Questionnaire Item Number: Person 32

FEFU Screen Name: JWLH

During the week of (<RDATE-7>), what time did (<Name>/you) usually leave for work?

(what hour?)

FEFU Screen Name: JWLM

(-- minutes past that hour?)

FEFU Screen Name: JWAM

(-- was that AM or PM?)

 1. AM

 2. PM

Paper Questionnaire Item Number: Person 33

FEFU Screen Name: JWMN

During the week of (<RDATE-7>), how many minutes did it usually take (<Name>/you) to get from home to work?

Paper Questionnaire Item Number: Person 34a

FEFU Screen Name: NWLA

During the week of (<RDATE-7>), (was <Name>/were you) on layoff from a job?

Paper Questionnaire Item Number: Person 34b

FEFU Screen Name: NWAB

During the week of (<RDATE-7>), (was <Name>/were you) TEMPORARILY absent from a job or business?

 1. Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc.

 2. No

Paper Questionnaire Item Number: Person 34c

FEFU Screen Name: NWRE

As of the week of (<RDATE-7>), had (<Name>/you) been informed that (<he/she>/you) would be recalled to work within the next six months OR been given a date to return to work?

Paper Questionnaire Item Number: Person 35

FEFU Screen Name: NWLK

As of the week of (<RDATE-7>), during the LAST 4 WEEKS, had (<Name>/you) been ACTIVELY looking for work?

Paper Questionnaire Item Number: Person 36

FEFU Screen Name: NWAV

During the week of (<RDATE-7>), could (<Name>/you) have started a job if offered one, or returned to work if recalled?

 1. YES, could have gone to work

 2. NO, because of temporary illness

 3. NO, because of all other reasons (in school, etc.)

Paper Questionnaire Item Number: Person 38b

FEFU Screen Name: WKW

How many weeks DID (<Name>/ you) work, even for a few hours, INCLUDING paid vacation, paid sick leave, and military service? Was it:

 1. 50 to 52 weeks

 2. 48 to 49 weeks

 3. 40 to 47 weeks

 4. 27 to 39 weeks

 5. 14 to 26 weeks

 6. 13 weeks or less

Paper Questionnaire Item Number: Person 41

FEFU Screen Name: INX1

((Was <Name>/ Were you) working on Active Duty in the US Armed forces?)

Paper Questionnaire Item Number: Person 46a

FEFU Screen Name: WAGX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any wages, salary, commissions, bonuses or tips?

FEFU Screen Name: WAG

IN THE PAST 12 MONTHS, what was the amount of the wages, salary, commissions, bonuses or tips that (<Name>/you) received?

Paper Questionnaire Item Number: Person 46b

FEFU Screen Name: SEMX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships?

FEFU Screen Name: SEM

IN THE PAST 12 MONTHS, what was the amount of the self-employment income that (<Name>/you) received?

FEFU Screen Name: SEML

Was that self-employment income a loss?

Paper Questionnaire Item Number: Person 46c

FEFU Screen Name: INTRX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any interest, dividends, net rental income, royalty income or income from estates and trusts?

FEFU Screen Name: INTR

IN THE PAST 12 MONTHS, what was the amount of the interest income, dividends, net rental income, royalty income or income from estates and trusts that (<Name>/you) received?

FEFU Screen Name: INTRL

Was that interest, dividends, net rental income, royalty income or income from estates and trusts income a loss?

Paper Questionnaire Item Number: Person 46d

FEFU Screen Name: SS

IN THE PAST 12 MONTHS, did (<Name>/you) receive any Social Security or Railroad Retirement income?

FEFU Screen Name: SSX

IN THE PAST 12 MONTHS, what was the amount of the Social Security or Railroad Retirement income that (<Name>/you) received?

Paper Questionnaire Item Number: Person 46e

FEFU Screen Name: SSIX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any Supplemental Security Income (SSI)?

FEFU Screen Name: SSI

IN THE PAST 12 MONTHS, what was the amount of the Supplemental Security Income (SSI) that (<Name>/you) received?

Paper Questionnaire Item Number: Person 46f

FEFU Screen Name: PAX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any public assistance or public welfare income?

FEFU Screen Name: PA

IN THE PAST 12 MONTHS, what was the amount of the public assistance or public welfare income that (<Name>/you) received?

Paper Questionnaire Item Number: Person 46g

FEFU Screen Name: RETX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any retirement, survivor or disability pensions?

FEFU Screen Name: RET

IN THE PAST 12 MONTHS, what was the amount of the retirement, survivor or disability pension that (<Name>/you) received?

Paper Questionnaire Item Number: Person 46h

FEFU Screen Name: OIX

IN THE PAST 12 MONTHS, did (<Name>/you) receive any other income on a REGULAR basis, such as -- VA payments, unemployment compensation, child support or alimony?

(Include all reoccurring income. Do not include one-time lump sum payments such as refunds, inheritances, withdrawals from savings or IRAs, etc.)

FEFU Screen Name: OI

IN THE PAST 12 MONTHS, what was the amount of the other income that (<Name>/you) received?

Paper Questionnaire Item Number: Person 47

FEFU Screen Name: TI

What was the total income for (<Name>/you) for the PAST 12 MONTHS?

FEFU Screen Name: TIN

Income received by (<Name>/you) IN THE PAST 12 MONTHS = NONE?

FEFU Screen Name: TIL

Was that income a loss?