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pdfDRAFT #1 (1-21-2009)
OMB No. 0607-0806: Approval Expires 12/31/2010
D-2(E)CNMI
FORM
(1-21-2009)
LCO
County
Block
Map Spot
AA
3 6 0 0
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
Unit ID
U.S. CENSUS BUREAU
➤
ENUMERATOR
QUESTIONNAIRE
APPLY LABEL HERE
➤
Commonwealth of
Norther Mariana
Islands –
2010 Census
Street or road name
Are there any continuation forms
for this address?
Yes – Number of forms
No
Physical description
Municipality
ZIP Code
9 6 7 9 9
S1. Hello, my name is (Your name) and I’m an official
census worker for Census 2010 in (Island).
(Show ID.)
S2. I’m here to complete a Census questionnaire for
this address. It should take about 10 minutes.
(Hand respondent Confidentiality Notice.) This explains
that your answers are confidential. Did you or
anyone in this household live here on
April 1, 2010?
Yes – Continue with question S3
No – SKIP to question S4
S3. Is this (house/apartment/mobile home) a vacation
or seasonal home, or does someone in this
household usually live here?
Vacation or seasonal home or held for occasional
use – SKIP to "Respondent Information" on back page
Usually lives here – SKIP to question S5
S4. (Only ask if no household member lived here on April 1.)
On April 1, was this unit vacant, or occupied by a
different household?
Vacant – SKIP to "Respondent Information" on back page
Occupied by a different household – Using a
knowledgeable respondent, complete this questionnaire
for the Census Day household
Not a housing unit – SKIP to "Respondent Information"
on back page
S5. We need to count people where they live and
sleep most of the time.
(Show Card A.) Please look at Card A. It contains
examples of people who should and should not
be counted at this place.
Based on these examples, how many people
were living or staying in this (house/apartment/
mobile home) on April 1?
Number of people
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797501
(1-21-2009)
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D-2(E)CNMI, Page 1, Pantone Cyan (10%, 20%, 50% & 100%)
2
ENUMERATOR NOTE: For questions 2 through 5, prompt respondent with names if needed, for example, "Let’s start with Bob."
1. Let’s make a list of all those people. Please
start with the name of an owner or renter
who was living here on April 1. Otherwise,
start with any adult living here.
2. (Show Card B.) Please look at Card B. How is
(Name) related to (Read name of Person 1) ?
Mark ✗ ONE box.
3. Is (Name)
male or
female?
Mark ✗ ONE box.
Person 1
✗ Person 1
Male
MI
First Name
Female
Last Name
Person 2
MI
First Name
Last Name
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
Other relative
Roomer or boarder
Housemate or
roommate
Unmarried partner
Other nonrelative
Male
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
Other relative
Roomer or boarder
Housemate or
roommate
Unmarried partner
Other nonrelative
Male
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
Other relative
Roomer or boarder
Housemate or
roommate
Unmarried partner
Other nonrelative
Male
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
Other relative
Roomer or boarder
Housemate or
roommate
Unmarried partner
Other nonrelative
Male
Female
Person 3
MI
First Name
Last Name
Female
Person 4
MI
First Name
Last Name
Female
Person 5
MI
First Name
Last Name
Female
ENUMERATOR NOTE: Refer to S5 on the cover. If the number of people is more than 5, add additional household
members to Form D-2(E)SUPP AS, Continuation Form.
§pl#¤
Form D-2(E)CNMI
797502
(1-21-2009)
Page 2 Solid black
D-2(E)CNMI, Page 2, Pantone Cyan (10%, 50% & 100%)
3
4. What was (Name’s) age on April 1, 2010?
What is (Name’s) date of birth? Please report babies
as age 0 when the child is less than 1 year old.
Print numbers in boxes.
5. What is (Name’s) ethnic origin or race? Read if necessary:
(For example: Chamorro, Samoan, White, Black, Carolinian,
Filipino, Japanese, Korean, Palauan, Tongan, and so on.)
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
§pl$¤
Form D-2(E)CNMI
797503
(1-21-2009)
Page 3 Solid black
D-2(E)CNMI, Page 3, Pantone Cyan (10%, 50% & 100%)
4
Person 1
6. Print the name of Person 1 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
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)
§pl%¤
Form D-2(E)CNMI
797504
(1-21-2009)
Page 4 Solid black
D-2(E)CNMI, Page 4, Pantone Cyan (10%, 50% & 100%)
5
Person 1 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
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
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
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) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
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) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pl&¤
Form D-2(E)CNMI
797505
(1-21-2009)
Page 5 Solid black
D-2(E)CNMI, Page 5, Pantone Cyan (10%, 50% & 100%)
6
Person 1 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) 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?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
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
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) 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.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pl’¤
Form D-2(E)CNMI
797506
(1-21-2009)
Page 6 Solid black
D-2(E)CNMI, Page 6, Pantone Cyan (10%, 50% & 100%)
7
Person 1 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pl(¤
Form D-2(E)CNMI
797507
(1-21-2009)
Page 7 Solid black
D-2(E)CNMI, Page 7, Pantone Cyan (10%, 50% & 100%)
8
Person 1 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
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
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
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 or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
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?
§pl)¤
Form D-2(E)CNMI
797508
(1-21-2009)
Page 8 Solid black
D-2(E)CNMI, Page 8, Pantone Cyan (10%, 50% & 100%)
9
Person 1 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
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) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pl*¤
Form D-2(E)CNMI
797509
(1-21-2009)
Page 9 Solid black
D-2(E)CNMI, Page 9, Pantone Cyan (10%, 50% & 100%)
10
Person 1 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
The next set of questions is about your household.
50.
Yes – What was the amount?
Annual amount – Dollars
$
,
A mobile home
A one-family house detached from any other house
A one-family house attached to one or more houses
Two houses – Applies only in American
Samoa
Three or more houses – Applies only in
American Samoa
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
A container
Boat, RV, van, etc.
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
None OR
49.
51.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
52.
Annual amount – Dollars
,
When did (Read name of Person 1) move into this
living quarters?
2009 or 2010
2000 to 2008
1990 to 1999
1980 to 1989
1970 to 1979
1969 or earlier
Yes – What was the amount?
$
About when was this building first built?
2009 or 2010
2000 to 2008
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
What was (your/...’s) total income during 2009?
Annual amount – Dollars
(Show Card L.) Which of these categories best
describes this building? Include all apartments,
flats, etc., even if vacant.
.00
No
Refer to question 50. Ask question 53 only if this is a HOUSE
or a MOBILE HOME. Otherwise, SKIP to question 54a.
53.
Is there a business (such as a store or shop)
or a medical office on this property?
Yes
No
§pl+¤
Form D-2(E)CNMI
797510
(1-21-2009)
Page 10 Solid black
D-2(E)CNMI, Page 10, Pantone Cyan (10%, 50% & 100%)
11
Person 1 – Continued
54a. How many separate rooms are in this living
quarters? Rooms must be separated by built-in
archways or walls that extend from floor to
ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
1 room
2 rooms
3 rooms
4 rooms
5 rooms
6 rooms
7 rooms
8 rooms
9 or more rooms
b. How many of these rooms are bedrooms? Count
as bedrooms those rooms you would list if this
living quarters were for sale or rent. If this is an
efficiency/studio apartment, mark ✗ "No bedroom."
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 or more bedrooms
55a. (Show Card M.) Do you have hot and cold piped
water? If "Yes," ASK – Is it in this unit?
If "No," ASK – Do you have cold piped water in this
unit, in this building, or outside this building?
Yes, in this unit
Yes, in this building, not in unit
No, only cold piped water in this unit
No, only cold piped water in this building
No, only cold piped water outside this building
No piped water
55d. What type of toilet facilities do you have?
Outhouse or privy
Other or none
56a. Are your MAIN cooking facilities located inside
or outside this building? Mark ✗ ONE box.
Inside this building
Outside this building
No cooking facilities – SKIP to question 56c
b. What type of cooking facilities are these?
Mark ✗ ONE box.
Electric stove
Kerosene stove
Gas stove
Microwave oven and non-portable burners
Microwave oven only
Other (fireplace, hotplate, etc.)
c. Do you have a refrigerator in this building?
Yes
No
d. Do you have a sink with piped water in this
building?
Yes
No
57.
Yes, a cell or mobile phone only
Yes, a landline only
Yes, both a cell or mobile phone and a landline
No
58.
b. Do you have a bathtub or shower? If "Yes," ASK – Is
it in this unit, in this building, or outside this
building?
Yes, in this unit
Yes, in this building, not in unit
Yes, outside this building
No
c. Do you have a flush toilet? If "Yes," ASK – Is it in
this unit, in this building, or outside this
building?
Yes, in this unit – SKIP to question 56a
Yes, in this building, not in unit – SKIP to question 56a
Yes, outside this building – SKIP to question 56a
No
Does this living quarters have telephone service
from which you can both make and receive
calls? If "Yes," ASK – Does it have a cell or mobile
phone only, a landline only, or both?
Do you have air conditioning? If "Yes," ASK – Is it a
central air-conditioning system, 1 individual
room unit, or 2 or more individual room units?
Yes, a central air-conditioning system (includes split-type)
Yes, 1 individual room unit
Yes, 2 or more individual room units
No
59.
How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?
None
1
2
3
4
5
6 or more
§pl,¤
Form D-2(E)CNMI
797511
(1-21-2009)
Page 11 Solid black
D-2(E)CNMI, Page 11, Pantone Cyan (10%, 50% & 100%)
12
Person 1 – Continued
60.
Do you or any member of this household have a
battery-operated radio? Count car radios,
transistors, and other battery-operated sets in
working order or needing only a new battery for
operation.
Yes
No
61a. Do you or any member of this household have a
home computer or laptop in working condition?
67.
What is the MAIN type of material used for the
foundation of this building? Mark ✗ ONE box.
Concrete
Wood pier or pilings
Other
68a. What is the average monthly cost for
electricity for this living quarters?
Average monthly cost – Dollars
Yes
No – SKIP to question 62
$
62.
Included in rent or condominium fee
No charge or electricity not used
b. What is the average monthly cost for gas for
this living quarters?
(Show Card N.) Do you get water from – Mark ✗
ONE box.
A public system only?
A public system and catchment?
A village water system only? – Applies only in
American Samoa
An individual well?
A catchment, tanks, or drums only?
Some other source, such as a standpipe,
spring, river, creek, etc.?
63.
Average monthly cost – Dollars
$
Yes
No
65.
c. What is the average monthly cost for water
and sewer for this living quarters?
Average monthly cost – Dollars
$
66.
What is the MAIN type of material used for
the roof of this building? Mark ✗ ONE box.
Poured concrete
Metal
Wood
Other
,
.00
OR
Included in rent or condominium fee
No charge
d. What is the average monthly cost for oil, coal,
kerosene, wood, etc. for this living quarters?
Average monthly cost – Dollars
What is the MAIN type of material used for
the outside walls of this building? Mark ✗
ONE box.
Poured concrete
Concrete blocks
Metal
Wood
Other
.00
Included in rent or condominium fee
Included in electricity payment entered above
No charge or gas not used
Is this building connected to a public sewer? If "No,"
ASK – Is it connected to a septic tank or cesspool
OR other means?
Is this living quarters part of a condominium?
,
OR
Yes, connected to a public sewer
No, connected to a septic tank or cesspool
No, use other means
64.
.00
OR
b. Do you or any member of this household
have an Internet connection at this living
quarters?
Yes
No
,
$
,
.00
OR
Included in rent or condominium fee
No charge or these fuels not used
69.
(Show Card O.) Is this living quarters – Mark ✗
ONE box.
Owned by you or someone in this household
with a mortgage or loan? Include home equity
loans.
Owned by you or someone in this household
free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
§pl-¤
Form D-2(E)CNMI
797512
(1-21-2009)
Page 12 Solid black
D-2(E)CNMI, Page 12, Pantone Cyan (10%, 50% & 100%)
13
Person 1 – Continued
Refer to question 69. Ask question 70 only if this living
quarters is RENTED. Otherwise, SKIP to question 71.
70.
74b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.
What is the monthly rent for this living
quarters?
Monthly amount – Dollars
Monthly amount – Dollars
$
,
$
,
.00
OR
.00
No regular payment required – SKIP to question 75a
71–76. Refer to question 69. Ask questions 71–76 only if
someone in this household OWNS or is BUYING this
living quarters. Otherwise, SKIP to the questions for
Person 2.
71.
About how much do you think this house and
lot, apartment, or mobile home (and lot, if
owned) would sell for if it were for sale?
Amount – Dollars
$
72.
,
,
Annual amount – Dollars
,
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required
d. Does the regular monthly mortgage payment
include payments for fire, hazard, typhoon,
or flood insurance on THIS property?
.00
What were the real estate taxes on THIS
property last year?
$
c. Does the regular monthly mortgage payment
include payments for real estate taxes on
THIS property?
.00
Yes, insurance included in mortgage payment
No, insurance paid separately or no insurance
75a. Do you or any member of this household have a
second mortgage or home equity loan on THIS
property? If "Yes," ASK – Is it a home equity loan,
a second mortgage, or both?
Yes, a home equity loan
Yes, a second mortgage
Yes, both second mortgage and home equity loan
No – SKIP to question 76
OR
None
73.
What was the annual payment for fire,
hazard, typhoon, and flood insurance on
THIS property?
Annual amount – Dollars
$
,
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
.00
OR
$
None
,
.00
OR
74a. Do you or any member of this 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
No – SKIP to question 75a
No regular payment required
Ask question 76 ONLY if this is a CONDOMINIUM.
76.
What is the monthly condominium fee?
Monthly amount – Dollars
$
77.
,
.00
Refer to S5 on the front cover. If more than one person
is listed, continue with Person 2. If not, SKIP to
"Respondent Information" on back page.
§pl.¤
Form D-2(E)CNMI
797513
(1-21-2009)
Page 13 Solid black
D-2(E)CNMI, Page 13, Pantone Cyan (10%, 50% & 100%)
14
Person 2
6. Print the name of Person 2 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
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)
§pl/¤
Form D-2(E)CNMI
797514
(1-21-2009)
Page 14 Solid black
D-2(E)CNMI, Page 14, Pantone Cyan (10%, 50% & 100%)
15
Person 2 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
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
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
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) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
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) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pl0¤
Form D-2(E)CNMI
797515
(1-21-2009)
Page 15 Solid black
D-2(E)CNMI, Page 15, Pantone Cyan (10%, 50% & 100%)
16
Person 2 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) 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?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
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
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) 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.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pl1¤
Form D-2(E)CNMI
797516
(1-21-2009)
Page 16 Solid black
D-2(E)CNMI, Page 16, Pantone Cyan (10%, 50% & 100%)
17
Person 2 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pl2¤
Form D-2(E)CNMI
797517
(1-21-2009)
Page 17 Solid black
D-2(E)CNMI, Page 17, Pantone Cyan (10%, 50% & 100%)
18
Person 2 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
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
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
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 or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
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?
§pl3¤
Form D-2(E)CNMI
797518
(1-21-2009)
Page 18 Solid black
D-2(E)CNMI, Page 18, Pantone Cyan (10%, 50% & 100%)
19
Person 2 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
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) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pl4¤
Form D-2(E)CNMI
797519
(1-21-2009)
Page 19 Solid black
D-2(E)CNMI, Page 19, Pantone Cyan (10%, 50% & 100%)
20
Person 2 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on the front cover. If more than one
person is listed, continue with Person 3. If not, SKIP to
"Respndent Information" on back page.
§pl5¤
Form D-2(E)CNMI
797520
(1-21-2009)
Page 20 Solid black
D-2(E)CNMI, Page 20, Pantone Cyan (10%, 50% & 100%)
21
Person 3
6. Print the name of Person 3 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
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)
§pl6¤
Form D-2(E)CNMI
797521
(1-21-2009)
Page 21 Solid black
D-2(E)CNMI, Page 21, Pantone Cyan (10%, 50% & 100%)
22
Person 3 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
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
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
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) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
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) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pl7¤
Form D-2(E)CNMI
797522
(1-21-2009)
Page 22 Solid black
D-2(E)AS, Page 22, Pantone Cyan (10%, 50% & 100%)
23
Person 3 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) 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?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
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
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) 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.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pl8¤
Form D-2(E)CNMI
797523
(1-21-2009)
Page 23 Solid black
D-2(E)CNMI, Page 23, Pantone Cyan (10%, 50% & 100%)
24
Person 3 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pl9¤
Form D-2(E)CNMI
797524
(1-21-2009)
Page 24 Solid black
D-2(E)CNMI, Page 24, Pantone Cyan (10%, 50% & 100%)
25
Person 3 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
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
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
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 or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
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?
§pl:¤
Form D-2(E)CNMI
797525
(1-21-2009)
Page 25 Solid black
D-2(E)CNMI, Page 25, Pantone Cyan (10%, 50% & 100%)
26
Person 3 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
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) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pl;¤
Form D-2(E)CNMI
797526
(1-21-2009)
Page 26 Solid black
D-2(E)CNMI, Page 26, Pantone Cyan (10%, 50% & 100%)
27
Person 3 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on the front cover. If more than three
persons are listed, continue with Person 4. If not,
SKIP to the "Respondent Information" on back cover.
§pl<¤
Form D-2(E)CNMI
797527
(1-21-2009)
Page 27 Solid black
D-2(E)CNMI, Page 27, Pantone Cyan (10%, 50% & 100%)
28
Person 4
6. Print the name of Person 4 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
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)
§pl=¤
Form D-2(E)CNMI
797528
(1-21-2009)
Page 28 Solid black
D-2(E)CNMI, Page 28, Pantone Cyan (10%, 50% & 100%)
29
Person 4 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
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
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
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) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
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) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pl>¤
Form D-2(E)CNMI
797529
(1-21-2009)
Page 29 Solid black
D-2(E)CNMI, Page 29, Pantone Cyan (10%, 50% & 100%)
30
Person 4 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) 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?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
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
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) 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.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pl?¤
Form D-2(E)CNMI
797530
(1-21-2009)
Page 30 Solid black
D-2(E)CNMI, Page 30, Pantone Cyan (10%, 50% & 100%)
31
Person 4 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pl@¤
Form D-2(E)CNMI
797531
(1-21-2009)
Page 31 Solid black
D-2(E)CNMI, Page 31, Pantone Cyan (10%, 50% & 100%)
32
Person 4 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
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
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
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 or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
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?
§plA¤
Form D-2(E)CNMI
797532
(1-21-2009)
Page 32 Solid black
D-2(E)CNMI, Page 32, Pantone Cyan (10%, 50% & 100%)
33
Person 4 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
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) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§plB¤
Form D-2(E)CNMI
797533
(1-21-2009)
Page 33 Solid black
D-2(E)CNMI, Page 33, Pantone Cyan (10%, 50% & 100%)
34
Person 4 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on the front cover. If more than four
persons are listed, continue with Person 5. If not,
SKIP to the "Respondent Information" on back page.
§plC¤
Form D-2(E)CNMI
797534
(1-21-2009)
Page 34 Solid black
D-2(E)CNMI, Page 34, Pantone Cyan (10%, 50% & 100%)
35
Person 5
6. Print the name of Person 5 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
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)
§plD¤
Form D-2(E)CNMI
797535
(1-21-2009)
Page 35 Solid black
D-2(E)CNMI, Page 35, Pantone Cyan (10%, 50% & 100%)
36
Person 5 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP
to question 18.
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
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
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) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
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) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§plE¤
Form D-2(E)CNMI
797536
(1-21-2009)
Page 36 Solid black
D-2(E)CNMI, Page 36, Pantone Cyan (10%, 50% & 100%)
37
Person 5 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) 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?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
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
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) 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.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§plF¤
Form D-2(E)CNMI
797537
(1-21-2009)
Page 37 Solid black
D-2(E)CNMI, Page 37, Pantone Cyan (10%, 50% & 100%)
38
Person 5 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§plG¤
Form D-2(E)CNMI
797538
(1-21-2009)
Page 38 Solid black
D-2(E)CNMI, Page 38, Pantone Cyan (10%, 50% & 100%)
39
Person 5 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
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
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
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 or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
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?
§plH¤
Form D-2(E)CNMI
797539
(1-21-2009)
Page 39 Solid black
D-2(E)CNMI, Page 39, Pantone Cyan (10%, 50% & 100%)
40
Person 5 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
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) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
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Form D-2(E)CNMI
797540
(1-21-2009)
Page 40 Solid black
D-2(E)CNMI, Page 40, Pantone Cyan (10%, 50% & 100%)
41
Person 5 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on the front cover. If more than five
persons are listed, continue with D-2(E)SUPP AS
form. If not, continue with the "Respondent
Information" on back page.
§plJ¤
Form D-2(E)CNMI
797541
(1-21-2009)
Page 41 Solid black
D-2(E)CNMI, Page 41, Pantone Cyan (10%, 50% & 100%)
42
RESPONDENT INFORMATION
R1. Enter respondent’s name.
First Name
R2. In case we need to contact you,
what is your telephone number
and the best time to call?
Area Code + Number
MI
-
Last Name
R3. Respondent type –
Household member
lived here on
April 1, 2010
Household member
moved in after
April 1, 2010
-
Day
Evening
Either
Neighbor or other
proxy
INTERVIEW SUMMARY
A. Status on April 1, 2010
1 = Occupied
2 = Vacant – Regular
3 = Vacant – Usual home elsewhere
4 = Demolished/Burned out/
Cannot locate
5 = Nonresidential
6 = Empty mobile home/trailer site
7 = Uninhabitable (open to elements,
condemned, under construction)
B. POP on April 1, 2010
C. VACANT – If vacant, ASK – Which
category best described this
vacant unit as of April 1, 2010?
(Read categories.)
01–49 = Total persons
00 = Vacant
98 = Delete
99 = POP unknown
For rent
Rented, not occupied
For sale only
Sold, not occupied
For seasonal, recreational,
or occasional use
For migrant workers
Other vacant
8 = Duplicate – Record ID of Dup.
D. UHE
E. MOV
F. PI
G. REF
H. CO
I. REP
J. VDC
K. JIC1
L. JIC2
RECORD OF CONTACT
Type
Month
Day
Time
Outcome
Type
Month
Day
Time
Outcome
:
a.m.
p.m.
Personal
Telephone
:
a.m.
p.m.
Personal
Telephone
:
a.m.
p.m.
Personal
Telephone
:
a.m.
p.m.
Personal
Telephone
:
a.m.
p.m.
Personal
Telephone
:
a.m.
p.m.
RE = Refusal
CI = Conducted interview
✗ Personal
OUTCOME CODES:
NV = Left Notice of Visit
NC = No contact
OT = Other
INTERVIEW SUMMARY
I certify that the entries I have made on this questionnaire are true and correct
to the best of my knowledge.
Crew Leader’s initials
CLD number
Enumerator’s signature and date
Month
Day
§plK¤
Form D-2(E)CNMI
797542
(1-21-2009)
Page 42 Solid black
D-2(E)CNMI, Page 42, Pantone Cyan (10%, 50% & 100%)
| File Type | application/pdf |
| File Modified | 2009-01-30 |
| File Created | 2009-01-30 |