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OMB No. 0607-0806: Approval Expires 12/31/2010
LCO
D-2(E)VI
FORM
(1-21-2009)
U.S. DEPARTMENT OF COMMERCE
County
Block
Map Spot
AA
Unit ID
Economics and Statistics Administration
U.S. CENSUS BUREAU
➤
APPLY LABEL HERE
➤
ENUMERATOR
QUESTIONNAIRE
U.S.
Virgin Islands
2010 Census
House #
Road name
Are there any continuation forms
for this address?
Plot #
Estate name
House #
Yes – Number of forms
No
Physical landmark/Other identifying information
Island
S1. Hello, my name is (Your name) and I’m an
official census worker for Census 2010
in the U.S. Virgin Islands (Show ID.).
S2. I’m here to complete a Census
questionnaire for this address. It
should take about 42 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. Does someone usually live at this
(house/apartment/mobile home), or is
this a vacation or seasonal home?
Usually lives here – SKIP to question S5
Vacation or seasonal home or held for
occasional use – SKIP to "Respondent
Information" on back page
ZIP Code
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
§ps"¤
798201
(1-21-2009)
Page 1 Solid black
D-2(E)VI, Page 1, Pantone Cyan (10%, 20%, 50% & 100%)
ENUMERATOR NOTE: For questions 2 through 5, prompt respondent with names if needed, for example, "Let’s start with Bob."
2
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 VI, Continuation Form.
§ps#¤
Form D-2(E)VI
798202
(1-21-2009)
Page 2 Solid black
D-2(E)VI, 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.
Age on April 1, 2010
DATE OF BIRTH
Month
Day
5. (Show Card C.) Please look at Card C. Is (Name) of Hispanic,
Latino, or Spanish Origin? Read if necessary: Examples of
another Hispanic, Latino, or Spanish origin include Argentinean,
Colombian, Cuban, Nicaraguan, Salvadoran, Spaniard, and so on.
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin – What is that
origin?
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin – What is that
origin?
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin – What is that
origin?
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin – What is that
origin?
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican American, Chicano
Yes, another Hispanic, Latino, or Spanish origin – What is that
origin?
Year of birth
§ps$¤
Form D-2(E)VI
798203
(1-21-2009)
Page 3 Solid black
D-2(E)VI, Page 3, Pantone Cyan (10%, 50% & 100%)
4
6. (Show Card D.) Please look at Card D and choose one or more races. For this census,
Hispanic origins are not races. What is (Name’s) race?
Read if necessary: Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
Examples of other Pacific Islander groups include Fijian, Tongan, and so on.
1
White
Black, African
American, or Negro
American Indian
or Alaska Native
What is the name of the enrolled or principal tribe?
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian – What is that group?
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Pacific Islander – What is that group?
Some other race – What is that group?
2
White
Black, African
American, or Negro
American Indian
or Alaska Native
What is the name of the enrolled or principal tribe?
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian – What is that group?
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Pacific Islander – What is that group?
Some other race – What is that group?
3
White
Black, African
American, or Negro
American Indian
or Alaska Native
What is the name of the enrolled or principal tribe?
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian – What is that group?
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Pacific Islander – What is that group?
Some other race – What is that group?
4
White
Black, African
American, or Negro
American Indian
or Alaska Native
What is the name of the enrolled or principal tribe?
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian – What is that group?
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Pacific Islander – What is that group?
Some other race – What is that group?
5
White
Black, African
American, or Negro
American Indian
or Alaska Native
What is the name of the enrolled or principal tribe?
Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian – What is that group?
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Pacific Islander – What is that group?
Some other race – What is that group?
§ps%¤
Form D-2(E)VI
798204
(1-21-2009)
Page 4 Solid black
D-2(E)VI, Page 4, Pantone Cyan (10%, 50% & 100%)
5
Person 1
7.
Print the name of Person 1 from page 2.
First Name
MI
12b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Nursery school, preschool
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)
Last Name
8.
9.
Where (were you/was ...) born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
13.
(Show Card E.) (Are you/Is ...) a CITIZEN of the
United States?
NO SCHOOLING COMPLETED
No schooling completed
Yes, born in the U.S. Virgin Islands – SKIP to question 11a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)
10.
(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.
NURSERY SCHOOL OR PRESCHOOL THROUGH
GRADE 12
Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
When did (you/...) come to the U.S. Virgin
Islands to stay? If (you have/... has) entered the
U.S. Virgin Islands more than once, what is the
latest year?
Print numbers in boxes.
Year
HIGH SCHOOL GRADUATE
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)
11a. Where was (your/...’s) mother born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
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)
b. Where was (your/...’s) father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
Doctorate degree (for example: PhD, EdD)
14.
12a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only nursery school or preschool, 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 13
(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
the U.S. Virgin Islands?
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands
Yes, public school, public college
Yes, private school, private college, home school
§ps&¤
Form D-2(E)VI
798205
(1-21-2009)
Page 5 Solid black
D-2(E)VI, Page 5, Pantone Cyan (10%, 50% & 100%)
6
Person 1 – Continued
15a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 16a
b. What is this language?
(For example: French, Spanish, Chinese, Italian)
c. How well (do you/does ...) speak English?
Very well
Well
Not well
Not at all
17.
(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–g.
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, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or
a disability . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
16a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify
b. Where did (you/...) live 1 year ago?
What is the name of the island in the U.S. Virgin
Islands, or the name of the U.S. state,
commonwealth, territory, or foreign country?
c. What is the name of the city, town, or village?
18a. (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
§ps’¤
Form D-2(E)VI
798206
(1-21-2009)
Page 6 Solid black
D-2(E)VI, Page 6, Pantone Cyan (10%, 50% & 100%)
7
Person 1 – Continued
Ask questions 19a–19c if this person is 5 years old or
over. Otherwise, SKIP to question 48.
19a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
23c. 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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Yes
No
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
24.
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 26a
No, never served in the military – SKIP to
question 27a
Ask question 20 if this person is 15 years old or over.
Otherwise, SKIP to question 48.
20.
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
21.
25.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
22.
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.
(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
23a. (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 24
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 24
§ps(¤
Form D-2(E)VI
798207
(1-21-2009)
Page 7 Solid black
D-2(E)VI, Page 7, Pantone Cyan (10%, 50% & 100%)
8
Person 1 – Continued
26a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a
Ask question 30 if this person answered "Car, truck, or van" in
question 29. Otherwise, SKIP to question 31.
30.
How many people, including (yourself/...),
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
31.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
32.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
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
27a. LAST WEEK, did (you/...) work for pay at a job (or
business)?
Yes – SKIP to question 28
No, did not work (or retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 33a
28.
At what location did (you/...) work LAST WEEK?
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 in the
U.S. Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?
Ask questions 33–36 if this person did NOT work last week.
Otherwise, SKIP to question 37.
33a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 33c
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 36
No – SKIP to question 34
b. What is the name of the city, town, or village?
29.
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? 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.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 37
Other method
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
34.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
Yes
No – SKIP to question 36
35.
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.)
§ps)¤
Form D-2(E)VI
798208
(1-21-2009)
Page 8 Solid black
D-2(E)VI, Page 8, Pantone Cyan (10%, 50% & 100%)
9
Person 1 – Continued
36.
When did (you/...) last work, even for a few days?
40.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
41.
What kind of work (were you/was ...) doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
42.
What were (your/...’s) most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
43.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time?
2005 to 2010
2004 or earlier, or never worked – SKIP to question 46
37–42. 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.
37.
(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 GOVERNMENT employee
(territorial, 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?
38.
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.
Yes
No – SKIP to question 46
Name of company, business, or other employer
44a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 45
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service?
39.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto repair shop, bank)
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
45.
During 2009, in the WEEKS WORKED, how many
hours did (you/...) usually work each WEEK?
Usual hours worked each WEEK
§ps*¤
Form D-2(E)VI
798209
(1-21-2009)
Page 9 Solid black
D-2(E)VI, Page 9, Pantone Cyan (10%, 50% & 100%)
10
Person 1 – Continued
46.
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?
Annual amount – Dollars
$
,
46e. 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
$
.00
,
.00
No
No
b. 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?
Annual amount – Dollars
$
,
g. 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
Loss
$
.00
,
.00
No
No
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
$
,
Do not ask question 47 if questions 46a-46g 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.
47.
What was (your/...’s) total income during 2009?
Loss
.00
Annual amount – Dollars
None OR
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
§ps+¤
Form D-2(E)VI
798210
(1-21-2009)
Page 10 Solid black
D-2(E)VI, Page 10, Pantone Cyan (10%, 50% & 100%)
11
Person 1 – Continued
The next set of questions is about your household.
48.
(Show Card L.) Which of these categories best
describes this building? Include all apartments,
flats, etc., even if vacant.
A mobile home
A one-family house detached from any other house
A one-family house attached to one or more houses
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 or more apartments
A boat or houseboat
RV, van, etc.
49.
54a. How many separate rooms are in this
(house/apartment/mobile home)? Rooms must be
separated by built-in archways or walls that
extend out at least 6 inches and go from floor to
ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
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
(house/apartment/mobile home) were for sale or
rent. If this is an efficiency/studio apartment, mark ✗ "No
bedroom."
When did (Read name of Person 1) move into this
(house/apartment/mobile home)?
2009 or 2010
2000 to 2008
1990 to 1999
1980 to 1989
1970 to 1979
1969 or earlier
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 or more bedrooms
55.
Refer to question 48. Ask questions 51–53 if this is a HOUSE
or a MOBILE HOME. Otherwise, SKIP to question 54a.
51.
How many acres is this house or mobile
home on?
Less than 1 acre – SKIP to question 53
1 to 9.9 acres
10 or more acres
52.
In 2009, what were the actual sales of all
agricultural products from this property?
None
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more
Is there a business (such as a store or
barber shop) or a medical office on this
property?
Yes
No
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
50.
53.
56.
Does this (house/apartment/
mobile home) have –
a. Hot and cold running water? . .
b. A flush toilet? . . . . . . . . . . . .
c. A bathtub or shower? . . . . . . .
d. A sink with a faucet? . . . . . . . .
e. A stove or range? . . . . . . . . .
f. A refrigerator? . . . . . . . . . . . .
Yes No
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Does this (house/apartment/mobile home) 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?
Yes, a cell or mobile phone only
Yes, a landline only
Yes, both a cell or mobile phone and a landline
No
§ps,¤
Form D-2(E)VI
798211
(1-21-2009)
Page 11 Solid black
D-2(E)VI, Page 11, Pantone Cyan (10%, 50% & 100%)
12
Person 1 – Continued
57.
How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home
for use by members of your household?
None
1
2
3
4
5
6 or more
58.
62.
Is this (house/apartment/mobile home) part of
a condominium?
Yes
No
63a. What is the average monthly cost for electricity
for this (house/apartment/mobile home)?
Average monthly cost – Dollars
$
Included in rent or condominium fee
No charge or electricity not used
b. What is the average monthly cost for gas for this
(house/apartment/mobile home)?
Average monthly cost – Dollars
$
c. What is the average monthly cost for water and
sewer for this (house/apartment/mobile home)?
Average monthly cost – Dollars
Yes
No
$
61.
Is this building connected to a public sewer?
If "No," ASK – Is it connected to a septic tank or
cesspool OR other means?
Yes, connected to a public sewer
No, connected to a septic tank or cesspool
No, use other means
,
.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
(house/apartment/mobile home)?
Average monthly cost – Dollars
$
b. (Show Card M.) During the past month, did anyone
in this (house/apartment/mobile home) purchase
any water from – Mark ✗ all that apply.
A water delivery vendor?
A supermarket or grocery store?
Neither
.00
Included in rent or condominium fee
Included in electricity payment entered above
No charge or gas not used
Yes
No – SKIP to question 60a
60a. (Show Card M.) Do you get water from –
Mark ✗ ONE box.
A public system only?
A public system and cistern?
A cistern, tanks, or drums only?
A public standpipe?
Some other source, such as an
individual well or spring?
,
OR
59a. Do you or any member of this household have a
home computer or laptop in working condition?
b. Do you or any member of this household
have an Internet connection at this
(house/apartment/mobile home)?
.00
OR
Which FUEL is used MOST for cooking in this
(house/apartment/mobile home)?
Mark ✗ ONE box.
Gas: bottled or tank
Electricity
Fuel oil, kerosene, etc.
Wood or charcoal
Other fuel
No fuel used
,
,
.00
OR
Included in rent or condominium fee
No charge or these fuels not used
64.
(Show Card N.) Is this (house/apartment/
mobile home) – 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?
§ps-¤
Form D-2(E)VI
798212
(1-21-2009)
Page 12 Solid black
D-2(E)VI, Page 12, Pantone Cyan (10%, 50% & 100%)
13
Person 1 – Continued
Refer to question 64. Ask questions 65a and 65b if this
(house/apartment/mobile home) is RENTED. Otherwise,
SKIP to question 66.
65a. What is the monthly rent for this
(house/apartment/mobile home)?
Monthly amount – Dollars
$
69b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.
Monthly amount – Dollars
$
.00
No regular payment required – SKIP to question 70a
Yes
c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
No
66–72. Refer to question 64. Ask questions 66–72 only if
someone in the household OWNS or IS BUYING this
(house/apartment/mobile home). Otherwise, SKIP to
the questions for Person 2.
Amount – Dollars
67.
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, or flood
insurance on THIS property?
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?
$
,
,
.00
Yes, insurance included in mortgage payment
No, insurance paid separately or no insurance
70a. 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?
What were the real estate taxes on THIS
property last year?
Yes, a home equity loan
Yes, a second mortgage
Yes, both second mortgage and home equity loan
No – SKIP to question 71
Annual amount – Dollars
$
,
.00
b. How much is the regular monthly payment
on all second or junior mortgages and all
home equity loans on THIS property?
OR
None
68.
What was the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
.00
OR
,
b. Does the monthly rent include any meals?
66.
,
,
.00
Monthly amount – Dollars
$
,
.00
OR
No regular payment required
OR
None
69a. 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 70a
§ps.¤
Form D-2(E)VI
798213
(1-21-2009)
Page 13 Solid black
D-2(E)VI, Page 13, Pantone Cyan (10%, 50% & 100%)
14
Person 1 – Continued
Ask question 71 ONLY if this is a CONDOMINIUM.
71.
What is the monthly condominium fee?
Monthly amount – Dollars
$
,
.00
Ask question 72 ONLY if this is a MOBILE HOME or a BOAT.
72.
What was the total annual cost for installment
loan payments, personal property taxes, site
rent, marina fee, registration fees, and license
fees on THIS mobile home or boat and its
site/slip last year. Exclude real estate taxes.
Monthly amount – Dollars
$
,
.00
73. Refer to S5 on the front cover. If more than one person
is listed, continue with Person 2. If not, SKIP to the
"Respondent Information" on back page.
§ps/¤
Form D-2(E)VI
798214
(1-21-2009)
Page 14 Solid black
D-2(E)VI, Page 14, Pantone Cyan (10%, 50% & 100%)
15
Person 2
7.
Print the name of Person 2 from page 2.
First Name
MI
12b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Nursery school, preschool
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)
Last Name
8.
9.
Where (were you/was ...) born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
13.
(Show Card E.) (Are you/Is ...) a CITIZEN of the
United States?
NO SCHOOLING COMPLETED
No schooling completed
Yes, born in the U.S. Virgin Islands – SKIP to question 11a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)
10.
(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.
NURSERY SCHOOL OR PRESCHOOL THROUGH
GRADE 12
Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
When did (you/...) come to the U.S. Virgin
Islands to stay? If (you have/... has) entered the
U.S. Virgin Islands more than once, what is the
latest year?
Print numbers in boxes.
Year
HIGH SCHOOL GRADUATE
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)
11a. Where was (your/...’s) mother born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
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)
b. Where was (your/...’s) father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
Doctorate degree (for example: PhD, EdD)
14.
12a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only nursery school or preschool, 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 13
(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
the U.S. Virgin Islands?
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands
Yes, public school, public college
Yes, private school, private college, home school
§ps0¤
Form D-2(E)VI
798215
(1-21-2009)
Page 15 Solid black
D-2(E)VI, Page 15, Pantone Cyan (10%, 50% & 100%)
16
Person 2 – Continued
15a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 16a
b. What is this language?
(For example: French, Spanish, Chinese, Italian)
c. How well (do you/does ...) speak English?
Very well
Well
Not well
Not at all
17.
(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–g.
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, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or
a disability . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
16a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify
b. Where did (you/...) live 1 year ago?
What is the name of the island in the U.S. Virgin
Islands, or the name of the U.S. state,
commonwealth, territory, or foreign country?
c. What is the name of the city, town, or village?
18a. (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
§ps1¤
Form D-2(E)VI
798216
(1-21-2009)
Page 16 Solid black
D-2(E)VI, Page 16, Pantone Cyan (10%, 50% & 100%)
17
Person 2 – Continued
Ask questions 19a–19c if this person is 5 years old or
over. Otherwise, SKIP to question 48.
19a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
23c. 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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Yes
No
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
24.
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 26a
No, never served in the military – SKIP to
question 27a
Ask question 20 if this person is 15 years old or over.
Otherwise, SKIP to question 48.
20.
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
21.
25.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
22.
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.
(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
23a. (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 24
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 24
§ps2¤
Form D-2(E)VI
798217
(1-21-2009)
Page 17 Solid black
D-2(E)VI, Page 17, Pantone Cyan (10%, 50% & 100%)
18
Person 2 – Continued
26a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a
Ask question 30 if this person answered "Car, truck, or van" in
question 29. Otherwise, SKIP to question 31.
30.
How many people, including (yourself/...),
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
31.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
32.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
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
27a. LAST WEEK, did (you/...) work for pay at a job (or
business)?
Yes – SKIP to question 28
No, did not work (or retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 33a
28.
At what location did (you/...) work LAST WEEK?
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 in the
U.S. Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?
Ask questions 33–36 if this person did NOT work last week.
Otherwise, SKIP to question 37.
33a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 33c
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 36
No – SKIP to question 34
b. What is the name of the city, town, or village?
29.
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? 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.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 37
Other method
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
34.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
Yes
No – SKIP to question 36
35.
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.)
§ps3¤
Form D-2(E)VI
798218
(1-21-2009)
Page 18 Solid black
D-2(E)VI, Page 18, Pantone Cyan (10%, 50% & 100%)
19
Person 2 – Continued
36.
When did (you/...) last work, even for a few days?
40.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
41.
What kind of work (were you/was ...) doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
42.
What were (your/...’s) most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
43.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time?
2005 to 2010
2004 or earlier, or never worked – SKIP to question 46
37–42. 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.
37.
(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 GOVERNMENT employee
(territorial, 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?
38.
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.
Yes
No – SKIP to question 46
Name of company, business, or other employer
44a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 45
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service?
39.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto repair shop, bank)
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
45.
During 2009, in the WEEKS WORKED, how many
hours did (you/...) usually work each WEEK?
Usual hours worked each WEEK
§ps4¤
Form D-2(E)VI
798219
(1-21-2009)
Page 19 Solid black
D-2(E)VI, Page 19, Pantone Cyan (10%, 50% & 100%)
20
Person 2 – Continued
46.
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?
Annual amount – Dollars
$
,
46e. 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
$
.00
,
.00
No
No
b. 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?
Annual amount – Dollars
$
,
g. 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
Loss
$
.00
,
.00
No
No
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
$
,
Do not ask question 47 if questions 46a-46g 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.
47.
What was (your/...’s) total income during 2009?
Loss
Annual amount – Dollars
.00
None OR
$
,
Loss
.00
No
48.
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
Refer to S5 on the front cover. If more than two persons
are listed, continue with Person 3. If not, SKIP to the
"Respondent Information" on back page.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
§ps5¤
Form D-2(E)VI
798220
(1-21-2009)
Page 20 Solid black
D-2(E)VI, Page 20, Pantone Cyan (10%, 50% & 100%)
21
Person 3
7.
Print the name of Person 3 from page 2.
First Name
MI
12b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Nursery school, preschool
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)
Last Name
8.
9.
Where (were you/was ...) born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
13.
(Show Card E.) (Are you/Is ...) a CITIZEN of the
United States?
NO SCHOOLING COMPLETED
No schooling completed
Yes, born in the U.S. Virgin Islands – SKIP to question 11a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)
10.
(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.
NURSERY SCHOOL OR PRESCHOOL THROUGH
GRADE 12
Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
When did (you/...) come to the U.S. Virgin
Islands to stay? If (you have/... has) entered the
U.S. Virgin Islands more than once, what is the
latest year?
Print numbers in boxes.
Year
HIGH SCHOOL GRADUATE
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)
11a. Where was (your/...’s) mother born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
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)
b. Where was (your/...’s) father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
Doctorate degree (for example: PhD, EdD)
14.
12a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only nursery school or preschool, 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 13
(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
the U.S. Virgin Islands?
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands
Yes, public school, public college
Yes, private school, private college, home school
§ps6¤
Form D-2(E)VI
798221
(1-21-2009)
Page 21 Solid black
D-2(E)VI, Page 21, Pantone Cyan (10%, 50% & 100%)
22
Person 3 – Continued
15a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 16a
b. What is this language?
(For example: French, Spanish, Chinese, Italian)
c. How well (do you/does ...) speak English?
Very well
Well
Not well
Not at all
17.
(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–g.
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, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or
a disability . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
16a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify
b. Where did (you/...) live 1 year ago?
What is the name of the island in the U.S. Virgin
Islands, or the name of the U.S. state,
commonwealth, territory, or foreign country?
c. What is the name of the city, town, or village?
18a. (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
§ps7¤
Form D-2(E)VI
798222
(1-21-2009)
Page 22 Solid black
D-2(E)VI, Page 22, Pantone Cyan (10%, 50% & 100%)
23
Person 3 – Continued
Ask questions 19a–19c if this person is 5 years old or
over. Otherwise, SKIP to question 48.
19a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
23c. 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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Yes
No
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
24.
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 26a
No, never served in the military – SKIP to
question 27a
Ask question 20 if this person is 15 years old or over.
Otherwise, SKIP to question 48.
20.
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
21.
25.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
22.
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.
(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
23a. (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 24
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 24
§ps8¤
Form D-2(E)VI
798223
(1-21-2009)
Page 23 Solid black
D-2(E)VI, Page 23, Pantone Cyan (10%, 50% & 100%)
24
Person 3 – Continued
26a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a
Ask question 30 if this person answered "Car, truck, or van" in
question 29. Otherwise, SKIP to question 31.
30.
How many people, including (yourself/...),
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
31.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
32.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
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
27a. LAST WEEK, did (you/...) work for pay at a job (or
business)?
Yes – SKIP to question 28
No, did not work (or retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 33a
28.
At what location did (you/...) work LAST WEEK?
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 in the
U.S. Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?
Ask questions 33–36 if this person did NOT work last week.
Otherwise, SKIP to question 37.
33a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 33c
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 36
No – SKIP to question 34
b. What is the name of the city, town, or village?
29.
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? 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.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 37
Other method
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
34.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
Yes
No – SKIP to question 36
35.
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.)
§ps9¤
Form D-2(E)VI
798224
(12-11-2008)
Page 24 Solid black
D-2(E)VI, Page 24, Pantone Cyan (10%, 50% & 100%)
25
Person 3 – Continued
36.
When did (you/...) last work, even for a few days?
40.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
41.
What kind of work (were you/was ...) doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
42.
What were (your/...’s) most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
43.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time?
2005 to 2010
2004 or earlier, or never worked – SKIP to question 46
37–42. 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.
37.
(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 GOVERNMENT employee
(territorial, 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?
38.
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.
Yes
No – SKIP to question 46
Name of company, business, or other employer
44a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 45
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service?
39.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto repair shop, bank)
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
45.
During 2009, in the WEEKS WORKED, how many
hours did (you/...) usually work each WEEK?
Usual hours worked each WEEK
§ps:¤
Form D-2(E)VI
798225
(1-21-2009)
Page 25 Solid black
D-2(E)VI, Page 25, Pantone Cyan (10%, 50% & 100%)
26
Person 3 – Continued
46.
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?
46e. 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
b. 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?
Annual amount – Dollars
$
,
g. 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
Loss
$
.00
,
.00
No
No
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
$
,
Do not ask question 47 if questions 46a-46g 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.
47.
What was (your/...’s) total income during 2009?
Loss
Annual amount – Dollars
.00
No
None OR
48.
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
$
,
Loss
.00
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 page.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
§ps;¤
Form D-2(E)VI
798226
(1-21-2009)
Page 26 Solid black
D-2(E)VI, Page 26, Pantone Cyan (10%, 50% & 100%)
27
Person 4
7.
Print the name of Person 4 from page 2.
First Name
MI
12b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Nursery school, preschool
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)
Last Name
8.
9.
Where (were you/was ...) born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
13.
(Show Card E.) (Are you/Is ...) a CITIZEN of the
United States?
NO SCHOOLING COMPLETED
No schooling completed
Yes, born in the U.S. Virgin Islands – SKIP to question 11a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)
10.
(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.
NURSERY SCHOOL OR PRESCHOOL THROUGH
GRADE 12
Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
When did (you/...) come to the U.S. Virgin
Islands to stay? If (you have/... has) entered the
U.S. Virgin Islands more than once, what is the
latest year?
Print numbers in boxes.
Year
HIGH SCHOOL GRADUATE
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)
11a. Where was (your/...’s) mother born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
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)
b. Where was (your/...’s) father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
Doctorate degree (for example: PhD, EdD)
14.
12a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only nursery school or preschool, 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 13
(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
the U.S. Virgin Islands?
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands
Yes, public school, public college
Yes, private school, private college, home school
§ps<¤
Form D-2(E)VI
798227
(1-21-2009)
Page 27 Solid black
D-2(E)VI, Page 27, Pantone Cyan (10%, 50% & 100%)
28
Person 4 – Continued
15a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 16a
b. What is this language?
(For example: French, Spanish, Chinese, Italian)
c. How well (do you/does ...) speak English?
Very well
Well
Not well
Not at all
17.
(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–g.
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, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or
a disability . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
16a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify
b. Where did (you/...) live 1 year ago?
What is the name of the island in the U.S. Virgin
Islands, or the name of the U.S. state,
commonwealth, territory, or foreign country?
c. What is the name of the city, town, or village?
18a. (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
§ps=¤
Form D-2(E)VI
798228
(1-21-2009)
Page 28 Solid black
D-2(E)VI, Page 28, Pantone Cyan (10%, 50% & 100%)
29
Person 4 – Continued
Ask questions 19a–19c if this person is 5 years old or
over. Otherwise, SKIP to question 48.
19a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
23c. 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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Yes
No
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
24.
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 26a
No, never served in the military – SKIP to
question 27a
Ask question 20 if this person is 15 years old or over.
Otherwise, SKIP to question 48.
20.
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
21.
25.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
22.
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.
(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
23a. (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 24
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 24
§ps>¤
Form D-2(E)VI
798229
(1-21-2009)
Page 29 Solid black
D-2(E)VI, Page 29, Pantone Cyan (10%, 50% & 100%)
30
Person 4 – Continued
26a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a
Ask question 30 if this person answered "Car, truck, or van" in
question 29. Otherwise, SKIP to question 31.
30.
How many people, including (yourself/...),
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
31.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
32.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
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
27a. LAST WEEK, did (you/...) work for pay at a job (or
business)?
Yes – SKIP to question 28
No, did not work (or retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 33a
28.
At what location did (you/...) work LAST WEEK?
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 in the
U.S. Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?
Ask questions 33–36 if this person did NOT work last week.
Otherwise, SKIP to question 37.
33a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 33c
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 36
No – SKIP to question 34
b. What is the name of the city, town, or village?
29.
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? 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.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 37
Other method
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
34.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
Yes
No – SKIP to question 36
35.
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.)
§ps?¤
Form D-2(E)VI
798230
(1-21-2009)
Page 30 Solid black
D-2(E)VI, Page 30, Pantone Cyan (10%, 50% & 100%)
31
Person 4 – Continued
36.
When did (you/...) last work, even for a few days?
40.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
41.
What kind of work (were you/was ...) doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
42.
What were (your/...’s) most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
43.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time?
2005 to 2010
2004 or earlier, or never worked – SKIP to question 46
37–42. 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.
37.
(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 GOVERNMENT employee
(territorial, 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?
38.
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.
Yes
No – SKIP to question 46
Name of company, business, or other employer
44a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 45
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service?
39.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto repair shop, bank)
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
45.
During 2009, in the WEEKS WORKED, how many
hours did (you/...) usually work each WEEK?
Usual hours worked each WEEK
§ps@¤
Form D-2(E)VI
798231
(1-21-2009)
Page 31 Solid black
D-2(E)VI, Page 31, Pantone Cyan (10%, 50% & 100%)
32
Person 4 – Continued
46.
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?
Annual amount – Dollars
$
,
46e. 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
$
.00
,
.00
No
No
b. 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?
Annual amount – Dollars
$
,
g. 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
Loss
$
.00
,
.00
No
No
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
$
,
Do not ask question 47 if questions 46a-46g 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.
47.
What was (your/...’s) total income during 2009?
Loss
Annual amount – Dollars
.00
None OR
$
,
Loss
.00
No
48.
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
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.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
§psA¤
Form D-2(E)VI
798232
(1-21-2009)
Page 32 Solid black
D-2(E)VI, Page 32, Pantone Cyan (10%, 50% & 100%)
33
Person 5
7.
Print the name of Person 5 from page 2.
First Name
MI
12b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Nursery school, preschool
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)
Last Name
8.
9.
Where (were you/was ...) born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
13.
(Show Card E.) (Are you/Is ...) a CITIZEN of the
United States?
NO SCHOOLING COMPLETED
No schooling completed
Yes, born in the U.S. Virgin Islands – SKIP to question 11a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)
10.
(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.
NURSERY SCHOOL OR PRESCHOOL THROUGH
GRADE 12
Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
When did (you/...) come to the U.S. Virgin
Islands to stay? If (you have/... has) entered the
U.S. Virgin Islands more than once, what is the
latest year?
Print numbers in boxes.
Year
HIGH SCHOOL GRADUATE
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)
11a. Where was (your/...’s) mother born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
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)
b. Where was (your/...’s) father born? Print
St. Croix, St. John, or St. Thomas if in the U.S. Virgin
Islands, or the name of the U.S. state, commonwealth,
territory, or foreign country.
Doctorate degree (for example: PhD, EdD)
14.
12a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only nursery school or preschool, 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 13
(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
the U.S. Virgin Islands?
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands
Yes, public school, public college
Yes, private school, private college, home school
§psB¤
Form D-2(E)VI
798233
(1-21-2009)
Page 33 Solid black
D-2(E)VI, Page 33, Pantone Cyan (10%, 50% & 100%)
34
Person 5 – Continued
15a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 16a
b. What is this language?
(For example: French, Spanish, Chinese, Italian)
c. How well (do you/does ...) speak English?
Very well
Well
Not well
Not at all
17.
(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–g.
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, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or
a disability . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
16a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 17
Yes, this house – SKIP to question 17
No, different house
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify
b. Where did (you/...) live 1 year ago?
What is the name of the island in the U.S. Virgin
Islands, or the name of the U.S. state,
commonwealth, territory, or foreign country?
c. What is the name of the city, town, or village?
18a. (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
§psC¤
Form D-2(E)VI
798234
(1-21-2009)
Page 34 Solid black
D-2(E)VI, Page 34, Pantone Cyan (10%, 50% & 100%)
35
Person 5 – Continued
Ask questions 19a–19c if this person is 5 years old or
over. Otherwise, SKIP to question 48.
19a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
23c. 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.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
Yes
No
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
24.
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 26a
No, never served in the military – SKIP to
question 27a
Ask question 20 if this person is 15 years old or over.
Otherwise, SKIP to question 48.
20.
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
21.
25.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
22.
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.
(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
23a. (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 24
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 24
§psD¤
Form D-2(E)VI
798235
(1-21-2009)
Page 35 Solid black
D-2(E)VI, Page 35, Pantone Cyan (10%, 50% & 100%)
36
Person 5 – Continued
26a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 27a
Ask question 30 if this person answered "Car, truck, or van" in
question 29. Otherwise, SKIP to question 31.
30.
How many people, including (yourself/...),
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
31.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
32.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
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
27a. LAST WEEK, did (you/...) work for pay at a job (or
business)?
Yes – SKIP to question 28
No, did not work (or retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 33a
28.
At what location did (you/...) work LAST WEEK?
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 in the
U.S. Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?
Ask questions 33–36 if this person did NOT work last week.
Otherwise, SKIP to question 37.
33a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 33c
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 36
No – SKIP to question 34
b. What is the name of the city, town, or village?
29.
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? 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.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 37
Other method
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
34.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
Yes
No – SKIP to question 36
35.
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.)
§psE¤
Form D-2(E)VI
798236
(1-21-2009)
Page 36 Solid black
D-2(E)VI, Page 36, Pantone Cyan (10%, 50% & 100%)
37
Person 5 – Continued
36.
When did (you/...) last work, even for a few days?
40.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
41.
What kind of work (were you/was ...) doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
42.
What were (your/...’s) most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
43.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time?
2005 to 2010
2004 or earlier, or never worked – SKIP to question 46
37–42. 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.
37.
(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 GOVERNMENT employee
(territorial, 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?
38.
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.
Yes
No – SKIP to question 46
Name of company, business, or other employer
44a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 45
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service?
39.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, newspaper
publishing, mail order house, auto repair shop, bank)
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
45.
During 2009, in the WEEKS WORKED, how many
hours did (you/...) usually work each WEEK?
Usual hours worked each WEEK
§psF¤
Form D-2(E)VI
798237
(1-21-2009)
Page 37 Solid black
D-2(E)VI, Page 37, Pantone Cyan (10%, 50% & 100%)
38
Person 5 – Continued
46.
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?
Annual amount – Dollars
$
,
46e. 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
$
.00
,
.00
No
No
b. 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?
Annual amount – Dollars
$
,
g. 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
Loss
$
.00
,
.00
No
No
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
$
,
Do not ask question 47 if questions 46a-46g 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.
47.
What was (your/...’s) total income during 2009?
Loss
Annual amount – Dollars
.00
None OR
$
,
Loss
.00
No
48.
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
Yes – What was the amount?
Refer to S5 on the front and cover. If more than five
persons are listed, continue with D-2(E) Supp VI form. If
not, continue with the "Respondent Information" on back
page.
Annual amount – Dollars
$
,
.00
No
§psG¤
Form D-2(E)VI
798238
(1-21-2009)
Page 38 Solid black
D-2(E)VI, Page 38, Pantone Cyan (10%, 50% & 100%)
39
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
J. VDC
I. REP
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
CERTIFICATION
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
§psH¤
Form D-2(E)VI
798239
(1-21-2009)
Page 39 Solid black
D-2(E)VI, Page 39, Pantone Cyan (10%, 50% & 100%)
| File Type | application/pdf |
| File Modified | 2009-01-29 |
| File Created | 2009-01-27 |