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DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
This questionnaire is available in either English or Spanish.
Se puede completar este cuestionario en español o en inglés.
To complete the English questionnaire, begin on
page 2. To complete the Spanish questionnaire, flip
this over and complete the green side.
Para completar cuestionario en inglés, comience en
la página 2. Para completar el cuestionario en
español, virélo y complete el lado verde.
Please complete this form as soon as possible.
Place it in the envelope provided and HOLD it for a
census representative to return to pick it up.
Por favor, complete este cuestionario tan
pronto sea posible. Colóquelo en el sobre que se
provee y GUÁRDELO hasta que un representante del
censo lo venga a recoger.
If you need help or have questions about
completing this form, call the number that our
census representative has given you.
Si necesita ayuda o tiene preguntas sobre cómo
completar este cuestionario, llame al número de
teléfono que le ha dado nuestro representante del
censo.
For more information about the American
Community Survey, visit our website at:
www.census.gov/acs.
CENSUS USE ONLY
Para obtener más información sobre la Encuesta
sobre la Comunidad Estadounidense, vaya a nuestra
página en la Internet: www.census.gov/acs.
How was this form completed?
English
ACS-1(GQ)(2008)
USCENSUSBUREAU
FORM
(06-05-2007) Draft 6
Spanish
OMB No. 0607-0810
§.;q1¤
ACS-1GQ, Page 1, Base (Black)
ACS-1GQ, Page 1, Blue Pantone 313 (15%)
ACS-1GQ, Page 1, green Pantone 354 (20%)
13268024
1
What is your name? Please print your name. 5
Include your telephone number, and today’s
date so we can contact you if there is a question.
What is your race? Mark (✗) one or more
boxes.
7 Are you a citizen of the United States?
B
Yes, born in the United States ➔ SKIP to
question 9a
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or
parents
Yes, U.S. citizen by naturalization – Print
year of naturalization.
White
Last Name
Black, African Am., or Negro
American Indian or Alaska Native – Print
name of enrolled or principal tribe.
First Name
MI
Area Code + Telephone Number
Today’s Date
Month Day
Asian Indian
Native Hawaiian
Chinese
Guamanian
or Chamorro
Samoan
Filipino
Year
Japanese
Korean
Vietnamese
2
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
What is your sex? Mark (✗) ONE box.
Male
What is your age and what is your date of
birth? Please report babies as age 0 when the
child is less than 1 year old.
Age (in years)
8 When did you come to live in the
Other Pacific
Islander – Print
race, for example,
Fijian, Tongan
and so on.
United States? Print numbers in boxes.
Year
9 a. At any time IN THE LAST 3 MONTHS, have
you attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a
college degree.
Female
3
No, not a U.S. citizen
Some other race – Print race.
Print numbers in boxes.
Month Day
Year of birth
No, have not attended in the last 3
months ➔ SKIP to question 10
Yes, public school, public college
Yes, private school, private college,
home school
6 Where were you born?
A
NOTE: Please answer BOTH Question 4
about Hispanic origin and Question 5
about race. For this survey, Hispanic
origins are not races.
In the United States – Print name of state.
b. What grade or level were you attending?
Mark (✗) ONE box.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 - 12
4
Are you of Hispanic, Latino, or Spanish
origin?
No, not of Hispanic, Latino, or
Spanish origin
Yes, Mexican, Mexican Am., Chicano
A
Outside the United States – Print name
of foreign country, or Puerto Rico,
Guam, etc.
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)
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish
origin – Print origin, for example,
Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and
so on.
2
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ACS-1GQ, Page 2, Base (Black)
ACS-1GQ, Page 2, Blue Pantone 313 (10, 15, 40, 50%)
13268032
10 What is the highest degree or level of
12 a. Do you speak a language other than
school you have COMPLETED? Mark (✗)
ONE box. If currently enrolled, mark the
previous grade or highest degree received.
English at home?
14 IN THE PAST 12 MONTHS, did you receive
Food Stamps or a Food Stamps benefit
card?
Yes
C
NO SCHOOLING COMPLETED
Yes
No ➔ SKIP to question 13a
No
b. What is this language?
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
15 Are you CURRENTLY covered by any of the
Nursery school
following types of health insurance or
health coverage plans? Mark "Yes" or "No"
for EACH type of coverage in items a – h.
(For example: Korean, Italian, Spanish,
Vietnamese)
Kindergarten
c. How well do you speak English?
Grade 1 through 11 – Specify
grade 1 – 11
a. Insurance through a current or
former employer or union (of
yours or your family member)
Very well
Well
Not well
HIGH SCHOOL GRADUATE
13 a. Did you live at this address 1 year ago?
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
No
b. Insurance purchased directly
from an insurance company
(by you or your family member)
Not at all
12th grade – NO DIPLOMA
Yes
c. Medicare, for people 65 and
older, or people with certain
disabilities
Person is under 1 year old ➔ SKIP to
question 15
Yes, at this address ➔ SKIP to
question 14
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 14
d. Medicaid, Medical Assistance,
or any kind of governmentassistance plan for those with
low incomes or a disability
e. TRICARE or other military
health care
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
f. VA (including if you have ever
used or enrolled for VA
health care)
No, at a different address in the
United States or Puerto Rico
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)
Doctorate degree (for example: PhD, EdD)
11 What is your ancestry or ethnic origin?
b. Where did you live 1 year ago?
g. Indian Health Service
Address (Number and street name)
h. Any other type of health
insurance or health coverage
plan – Specify
Name of city, town, post office, military
installation, or base
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Ukrainian, and so on.)
Name of U.S. county or municipio in
Puerto Rico
Name of U.S. state or
Puerto Rico
ZIP Code
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ACS-1GQ(PR), Page 3, Base (Black)
3
ACS-1GQ(PR), Page 3, Blue Pantone 313 (15, 40, 100%)
In total, how many years of active-duty
military service have you had?
13268040
16 a. Are you deaf or do you have serious
19 What is your marital status?
25 Have you ever served on active duty in the
U.S. Armed Forces, military Reserves, or
National Guard? Active duty does not include
training for the Reserves or National Guard, but
DOES include activation, for example, for the
Persian Gulf War.
difficulty hearing?
Now married
Yes
Widowed
No
Divorced
Separated
b. Are you blind or do you have serious
difficulty seeing even when wearing
glasses?
Yes, on active duty during the last 12
months, but not now
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
20 In the PAST 12 MONTHS did you get:
Yes
Yes
No
B
Yes, now on active duty
Never married ➔ SKIP to D
No
a. Married?
b. Widowed?
Answer question 17 if you are 5 years
old or over. Otherwise, SKIP to H on
page 7 for further instructions; do not
answer any more questions.
c. Divorced?
21 How many times have you been married?
26 When did you serve on active duty in the
U.S. Armed Forces? Mark (✗) a box for EACH
period in which you served, even if just for part
of the period.
Once
Two times
17 a. Because of a physical, mental or
emotional condition, do you have
serious difficulty concentrating,
remembering or making decisions?
D
Three or more times
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
22 In what year did you last get married?
Year
Yes
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
b. Do you have serious difficulty walking
or climbing stairs?
D
Yes
Answer question 23 if you are female
and 15–50 years old. Otherwise, SKIP to
question 24a.
March 1961 to July 1964
February 1955 to February 1961
No
Korean War (July 1950 to January 1955)
past 12 months?
World War II (December 1941 to
December 1946)
November 1941 or earlier
Yes
Yes
No
No
24 a. Do you have any of your own
C
grandchildren under the age of 18
living in this place?
Answer question 18 if you are 15 years
old or over. Otherwise, SKIP to H on
page 7 for further instructions; do not
answer any more questions.
18 Because of a physical, mental, or emotional
condition, do you have difficulty doing
errands alone such as visiting a doctor’s
office or shopping?
Yes
No
27 a. Do you have a VA service-connected
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 25
No ➔ SKIP to question 28a
b. Are you currently responsible for most
of the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this
place?
b. What is your service-connected
disability rating?
0 percent
Yes
10 or 20 percent
No ➔ SKIP to question 25
30 or 40 percent
c. How long have you been responsible
for the(se) grandchild(ren)? If you are
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom you have been
responsible the longest period of time.
Less than 6 months
3 or 4 years
6 to 11 months
5 or more
years
§.;qI¤
ACS-1GQ, Page 4, Base (Black)
disability rating?
Yes
1 or 2 years
4
January 1947 to June 1950
23 Have you given birth to any children in the
c. Do you have difficulty dressing or
bathing?
ACS-1GQ, Page 4, Blue Pantone 313 (10, 15, 40, 50%)
50 or 60 percent
70 percent or higher
13268057
28 a. LAST WEEK, did you work for pay at a
E
job (or business)?
Yes ➔ SKIP to question 29
Answer question 31 if you marked
"Car, truck, or van" in question 30.
Otherwise, SKIP to question 32.
35 During the LAST 4 WEEKS, have you been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 37
No – Did not work (or retired)
31 How many people, including yourself,
usually rode to work in the car, truck, or
van LAST WEEK?
Person(s)
b. LAST WEEK, did you do ANY work for
pay, even for as little as one hour?
Yes
36 LAST WEEK, could you have started a job if
offered one, or returned to work if recalled?
Yes, could have gone to work
No ➔ SKIP to question 34a
No, because of own temporary illness
29 At what location did you work LAST
No, because of all other reasons
(in school, etc.)
32 What time did you usually leave this
WEEK? If you worked at more than one
location, print where you worked most
last week.
address to go to work LAST WEEK?
Hour
a. Address (Number and street name)
37 When did you last work, even for a
few days?
Minute
a.m.
:
Within the past 12 months
p.m.
If the exact address is not known, give a
33 How many minutes did it usually take
description of the location such as the building
you to get from this address to work
name or the nearest street or intersection.
LAST WEEK?
b. Name of city, town, post office, military
installation, or base
1 to 5 years ago ➔ SKIP to G
Over 5 years ago or never worked ➔ SKIP
to question 46
38 a. During the PAST 12 MONTHS (52 weeks),
did you work 50 or more weeks? Count
paid time off as work.
Minutes
c. Is the work location inside the limits of
that city or town?
F
Yes ➔ SKIP to question 39
No
Answer questions 34–37 if you did
NOT work last week. Otherwise,
SKIP to question 38a.
b. How many weeks DID you work, even
for a few hours, including paid vacation,
paid sick leave, and military service?
Yes
No, outside the city/town limits
34 a. LAST WEEK, were you on layoff from
a job?
d. Name of county
Yes ➔ SKIP to question 34c
50 to 52 weeks
27 to 39 weeks
48 to 49 weeks
14 to 26 weeks
40 to 47 weeks
13 weeks or less
No
e. Name of U.S. state or
foreign country
b. LAST WEEK, were you TEMPORARILY
absent from a job or business?
f. ZIP code
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 37
No ➔ SKIP to question 35
30 How did you usually get to work LAST
WEEK? If you usually used more than one
method of transportation during the trip,
mark (✗) the box of the one used for most
of the distance.
E
Yes ➔ SKIP to question 36
Bus or trolley bus
Bicycle
No
Streetcar or
trolley car
Subway or elevated
Walked
Railroad
Worked at this
address ➔ SKIP
to question 38a
Ferryboat
Other method
WORKED, how many hours did you usually
work each WEEK?
Usual hours worked each WEEK
c. Have you been informed that you will be
recalled to work within the next 6 months
OR been given a date to return to work?
Motorcycle
Car, truck, or van
39 During the PAST 12 MONTHS, in the WEEKS
Taxicab
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ACS-1GQ, Page 5, Base (Black)
5
ACS-1GQ, Page 5, Blue Pantone 313 (10, 15, 40, 50%)
In total, how many years of active-duty
military service have you had?
13268065
G
44 What kind of work were you doing? (For
Answer questions 40–45 if you worked
in the past 5 years. Otherwise, SKIP to
question 46.
example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant.)
40–45 CURRENT OR MOST RECENT JOB ACTIVITY
Describe clearly your chief job activity or
business last week. If you had more than one
job, describe the one at which you worked the 45
most hours. If you did not have a job or
business last week, give the information for
your last job or business.
40 Were you – Mark (✗) ONE box.
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
41 For whom did you work?
If now on active duty in the Armed Forces,
mark (✗) this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
$
a. Did you receive any wages, salary,
commissions, bonuses, or tips in the
PAST 12 MONTHS?
f. Did you receive any public assistance or
welfare payments from the state or local
welfare office in the PAST 12 MONTHS?
Yes ➔ What was the amount?
Total amount - Dollars
$
g. Did you receive any retirement, survivor,
or disability pensions in the PAST 12
MONTHS? Do NOT include Social Security.
Yes ➔ What was the amount?
Total amount - Dollars
$
h. Did you have any other sources of income
received regularly such as Veterans’ (VA)
payments, unemployment compensation,
child support, or alimony in the PAST 12
MONTHS? Do NOT include lump sum
payments such as money from an inheritance
or sale of a home.
Yes ➔ What was the amount?
Total amount - Dollars
Loss
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
.00
No
Yes ➔ What was the net income
after business expenses?
Total amount - Dollars
,
,
.00
b. Did you have any self-employment
income from your own nonfarm or farm
businesses, including proprietorships and
partnerships, in the PAST 12 MONTHS?
$
.00
,
No
Yes ➔ What was the amount from
all jobs before deductions for
taxes, bonds, dues, or other
items?
Total amount - Dollars
43 Is this mainly – Mark (✗) ONE box.
.00
,
No
For income received jointly with someone else,
report only your share of the amount received
or earned.
No
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank.)
e. Did you receive any Supplemental
Security Income (SSI) in the PAST 12
MONTHS?
Yes ➔ What was the amount?
Total amount - Dollars
Mark (✗) the "Yes" box for each type of income
you 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.)
Mark (✗) the "No" box to show the types of
income NOT received.
If your net income was a loss, mark the "Loss"
box to the right of the dollar amount.
,
.00
,
No
46 INCOME IN THE PAST 12 MONTHS
$
42 What kind of business or industry was this?
Yes ➔ What was the amount?
Total amount - Dollars
$
What were your most important activities
or duties? (For example: caring for patients,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records.)
F
an employee of a PRIVATE FOR PROFIT
company or business, or of an individual,
for wages, salary, or commissions?
an employee of a PRIVATE NOT FOR
PROFIT, tax-exempt, or charitable
organization?
a local GOVERNMENT employee (city,
county, etc.)?
a state GOVERNMENT employee?
d. Did you receive any Social Security or
Railroad Retirement income in the PAST
12 MONTHS
.00
$
No
,
.00
No
c. Did you receive any interest, dividends,
net rental income, royalty income, or
income from estates and trusts in the
PAST 12 MONTHS? Report even small
amounts credited to an account.
Yes ➔ What was the amount?
Total amount - Dollars
47 What was your total income during the
PAST 12 MONTHS? Add entries 46a–46h;
subtract any losses. If net income was a loss,
enter the amount and mark (✗) the "Loss" box
next to the dollar amount.
Total amount - Dollars
Loss
Loss
$
,
.00
None
OR
$
,
,
.00
No
6
§.;qb¤
ACS-1GQ, Page 6, Base (Black)
ACS-1GQ, Page 6, Blue Pantone 313 (10, 15, 40, and 50%)
In total, how many years of active-duty
military service have you had?
13268073
H Thank you very much for your
participation.
Place the questionnaire in the
envelope and HOLD for your Census
Bureau Representative to pick up.
The Census Bureau estimates that this form will take about 25 minutes to complete, including the time for reviewing the instructions and answers. Send
comments regarding this burden estimate, including suggestions for reducing this burden, to: Paperwork Project 0607-0810, U.S. Census Bureau, 4700
Silver Hill Road, Stop 1500, Washington, DC 20233-1500. You may email comments to [email protected]; use "Paperwork Project 0607-0810" as
the subject.
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.
§.;qj¤
ACS-1GQ, Page 7, Base (Black)
7
ACS-1GQ, Page 7, Blue Pantone 313 (15, 50%)
In total, how many years of active-duty
military service have you had?
13268081
CENSUS USE ONLY
1. Who answered the majority of the questions on this questionnaire? Mark (✗) one box.
Sample person
Proxy for the sampled person
Don’t know
2. How were the majority of the questions on this questionnaire completed? Mark (✗) one box.
Personal interview
Telephone interview
Self-response
Don’t know
3. Were administrative records used to complete any of the questions on this
questionnaire? Mark (✗) one box.
No
Some administrative record information was used to complete this questionnaire
All responses on this questionnaire were obtained from administrative record information
Don’t know
Reason (code 219 or 243):
Final Outcome Codes
Mark (✗) ONE of the codes below to indicate the
final outcome of the case. If code 219 or 243 is
marked, explain reason in space below.
Interview
201
203
Out of scope
Noninterview
213
214
215
217
218
219
233
241
243
Other – Specify
I have reviewed the questionnaire for completeness.
FR’s name
8
FR’s code
Date of interview
§.;qr¤
ACS-1GQ, Page 8, Base (Black)
ACS-1GQ, Page 8, Blue Pantone 313 (15 and 40%)
13278015
DEPARTAMENTO DE COMERCIO DE LOS EE.UU.
DC Encuesta sobre la Comunidad Estadounidense
Administración de Economía y Estradísticas
Oficina del Censo de los EE.UU.
LA
This questionnaire is available in either English or Spanish.
Se puede completar este cuestionario en español o en inglés.
To complete the English questionnaire, begin on
page 2. To complete the Spanish questionnaire, flip
this over and complete the green side.
Para completar cuestionario en inglés, comience en
la página 2. Para completar el cuestionario en
español, virélo y complete el lado verde.
Please complete this form as soon as possible.
Place it in the envelope provided and HOLD it for a
census representative to return to pick it up.
Por favor, complete este cuestionario tan
pronto sea posible. Colóquelo en el sobre que se
provee y GUÁRDELO hasta que un representante del
censo lo venga a recoger.
If you need help or have questions about
completing this form, call the number that our
census representative has given you.
Si necesita ayuda o tiene preguntas sobre cómo
completar este cuestionario, llame al número de
teléfono que le ha dado nuestro representante del
censo.
For more information about the American
Community Survey, visit our website at:
www.census.gov/acs.
Para obtener más información sobre la Encuesta
sobre la Comunidad Estadounidense, vaya a nuestra
página en la Internet: www.census.gov/acs.
ACS-1(GQ)(2008)
USCENSUSBUREAU
FORM
(06-14-2007) Draft 1
OMB No. 0607-0810
§.| File Type | application/pdf |
| File Title | acs1gq_p01_08.g |
| File Modified | 2007-06-18 |
| File Created | 2007-06-14 |