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pdfDRAFT #1 (1-21-2009)
OMB No. 0607-0806: Approval Expires 12/31/2010
TRANSCRIBE FROM THE ADDRESS LABEL AREA ON FORM D-2(E)AS OR D-13 AS
LCO
County
Block
AA
Map Spot
3 4 0 0
Unit ID
Form
Physical description
of
Form(s)
ZIP Code
District/Island
9 6 7 9 9
CONTINUATION FORM
Census 2010–American Samoa
D-2(E)SUPP AS
FORM
(1-21-2009)
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
§pn"¤
797701
(1-21-2009)
Page 1 Solid black
D-2(E)SUPP AS, Page 1, Pantone Cyan (10%, 20%, & 50%)
2
ENUMERATOR NOTE: For questions 2 through 5, prompt respondent with names if needed, for example, "Let’s start with Bob."
1. Let’s make a list of all those people. Please
start with the name of an owner or renter
who was living here on April 1. Otherwise,
start with any adult living here.
2. (Show Card B.) Please look at Card B. How is
(Name) related to (Read name of Person 1) ?
Mark ✗ ONE box.
3. Is (Name)
male or
female?
Mark ✗ ONE box.
Person 6
✗ Person 1
Male
MI
First Name
Female
Last Name
Person 7
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 8
MI
First Name
Last Name
Female
Person 9
MI
First Name
Last Name
Female
Person 10
MI
First Name
Last Name
Female
ENUMERATOR NOTE: Refer to S5 on the cover. If the number of people is more than 5, add additional household
members to Form D-2(E)SUPP AS, Continuation Form.
§pn#¤
Form D-2(E)SUPP AS
797702
(1-21-2009)
Page 2 Solid black
D-2(ES)SUPP AS, Page 2, Pantone Cyan (10%, 50% & 100%)
3
4. What was (Name’s) age on April 1, 2010?
What is (Name’s) date of birth? Please report babies
as age 0 when the child is less than 1 year old.
Print numbers in boxes.
5. What is (Name’s) ethnic origin or race? Read if necessary:
(For example: Chamorro, Samoan, White, Black, Carolinian,
Filipino, Japanese, Korean, Palauan, Tongan, and so on.)
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
Age on April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth
§pn$¤
Form D-2(E)SUPP AS
797703
(1-21-2009)
Page 3 Solid black
D-2(E)SUPP AS, Page 3, Pantone Cyan (10%, 50% & 100%)
4
Person 6
6. Print the name of Person 1 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)
§pn%¤
Form D-2(E)SUPP AS
797704
(1-21-2009)
Page 4 Solid black
D-2(E)SUPP AS, Page 4, Pantone Cyan (10%, 50% & 100%)
5
Person 6 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . . .
e. TRICARE or other military health care . .
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pn&¤
Form D-2(E)SUPP AS
797705
(1-21-2009)
Page 5 Solid black
D-2(E)SUPP AS, Page 5, Pantone Cyan (10%, 50% & 100%)
6
Person 6 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) currently responsible for most of
the basic needs of any grandchild(ren) under the
age of 18 who live(s) in this house or apartment?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 27a
No, never served in the military – SKIP to
question 28a
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) ever served on
active duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty does
not include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pn’¤
Form D-2(E)SUPP AS
797706
(1-21-2009)
Page 6 Solid black
D-2(E)SUPP AS, Page 6, Pantone Cyan (10%, 50% & 100%)
7
Person 6 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pn(¤
Form D-2(E)SUPP AS
797707
(1-21-2009)
Page 7 Solid black
D-2(E)SUPP AS, Page 7, Pantone Cyan (10%, 50% & 100%)
8
Person 6 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
For whom did (you/...) work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual,
for wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business
or farm?
§pn)¤
Form D-2(E)SUPP AS
797708
(1-21-2009)
Page 8 Solid black
D-2(E)SUPP AS, Page 8, Pantone Cyan (10%, 50% & 100%)
9
Person 6 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
report, if possible, the appropriate share for
each person; otherwise, report the whole
amount for only one person (and mark ✗ the "No"
box for the other person) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pn*¤
Form D-2(E)SUPP AS
797709
(1-21-2009)
Page 9 Solid black
D-2(E)SUPP AS, Page 9, Pantone Cyan (10%, 50% & 100%)
10
Person 6 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S65 on Form D-2(E)AS. If the number of
people is more than six, continue on the next page. If
not, SKIP to the "Respondent Information" block on
page 42 of form D-2(E)AS.
§pn+¤
Form D-2(E)SUPP AS
797710
(1-21-2009)
Page 10 Solid black
D-2(E)SUPP AS, Page 10, Pantone Cyan (10%, 50% & 100%)
11
Person 7
6. Print the name of Person 2 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)
§pn,¤
Form D-2(E)SUPP AS
797711
(1-21-2009)
Page 11 Solid black
D-2(E)SUPP AS, Page 11, Pantone Cyan (10%, 50% & 100%)
12
Person 7 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . .
e. TRICARE or other military health care
.
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pn-¤
Form D-2(E)SUPP AS
797712
(1-21-2009)
Page 12 Solid black
D-2(E)SUPP AS, Page 12, Pantone Cyan (10%, 50% & 100%)
13
Person 7 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) currently responsible for most of
the basic needs of any grandchild(ren) under the
age of 18 who live(s) in this house or apartment?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 27a
No, never served in the military – SKIP to
question 28a
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) ever served on
active duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty does
not include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pn.¤
Form D-2(E)AS
797713
(1-21-2009)
Page 13 Solid black
D-2(E)SUPP AS, Page 13, Pantone Cyan (10%, 50% & 100%)
14
Person 7 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pn/¤
Form D-2(E)SUPP AS
797714
(1-21-2009)
Page 14 Solid black
D-2(E)SUPP AS, Page 14, Pantone Cyan (10%, 50% & 100%)
15
Person 7 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
For whom did (you/...) work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual,
for wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business
or farm?
§pn0¤
Form D-2(E)SUPP AS
797715
(1-21-2009)
Page 15 Solid black
D-2(E)SUPP AS, Page 15, Pantone Cyan (10%, 50% & 100%)
16
Person 7 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
report, if possible, the appropriate share for
each person; otherwise, report the whole
amount for only one person (and mark ✗ the "No"
box for the other person) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pn1¤
Form D-2(E)SUPP AS
797716
(1-21-2009)
Page 16 Solid black
D-2(E)SUPP AS, Page 16, Pantone Cyan (10%, 50% & 100%)
17
Person 7 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on form D-2(E) AS. If the number of
people is more than seven, continue on the next page.
If not, SKIP to the "Respondent Information" block on
page 42 of form D-2(E) AS.
§pn2¤
Form D-2(E)SUPP AS
797717
(1-21-2009)
Page 17 Solid black
D-2(E)SUPP AS, Page 17, Pantone Cyan (10%, 50% & 100%)
18
Person 8
6. Print the name of Person 3 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)
§pn3¤
Form D-2(E)SUPP AS
797718
(1-21-2009)
Page 18 Solid black
D-2(E)SUPP AS, Page 18, Pantone Cyan (10%, 50% & 100%)
19
Person 8 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . .
e. TRICARE or other military health care
.
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Local medical programs for indigents . .
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pn4¤
Form D-2(E)SUPP AS
797719
(1-21-2009)
Page 19 Solid black
D-2(E)SUPP AS, Page 19, Pantone Cyan (10%, 50% & 100%)
20
Person 8 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) currently responsible for most of
the basic needs of any grandchild(ren) under the
age of 18 who live(s) in this house or apartment?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 27a
No, never served in the military – SKIP to
question 28a
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) ever served on
active duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty does
not include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pn5¤
Form D-2(E)SUPP AS
797720
(1-21-2009)
Page 20 Solid black
D-2(E)SUPP AS, Page 20, Pantone Cyan (10%, 50% & 100%)
21
Person 8 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pn6¤
Form D-2(E)SUPP AS
797721
(1-21-2009)
Page 21 Solid black
D-2(E)SUPP AS, Page 21, Pantone Cyan (10%, 50% & 100%)
22
Person 8 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
For whom did (you/...) work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual,
for wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business
or farm?
§pki¤
Form D-2(E)SUPP AS
797722
(1-21-2009)
Page 22 Solid black
D-2(E)SUPP AS, Page 22, Pantone Cyan (10%, 50% & 100%)
23
Person 3 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
report, if possible, the appropriate share for
each person; otherwise, report the whole
amount for only one person (and mark ✗ the "No"
box for the other person) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pn8¤
Form D-2(E)SUPP AS
797723
(1-21-2009)
Page 23 Solid black
D-2(E)SUPP AS, Page 23, Pantone Cyan (10%, 50% & 100%)
24
Person 8 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on form D-2(E)AS. If the number of people
is more than eight, continue on the next page. If not,
SKIP to the "Respondent Information" block on page
42 of form D-2(E)AS.
§pn9¤
Form D-2(E)SUPP AS
797724
(1-21-2009)
Page 24 Solid black
D-2(E)SUPP AS, Page 24, Pantone Cyan (10%, 50% & 100%)
25
Person 9
6. Print the name of Person 4 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)
§pn:¤
Form D-2(E)SUPP AS
797725
(1-21-2009)
Page 25 Solid black
D-2(E)SUPP AS, Page 25, Pantone Cyan (10%, 50% & 100%)
26
Person 9 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP to
question 18.
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . . .
e. TRICARE or other military health care . .
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Local medical programs for indigents
..
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pn;¤
Form D-2(E)SUPP AS
797726
(1-21-2009)
Page 26 Solid black
D-2(E)SUPP AS, Page 26, Pantone Cyan (10%, 50% & 100%)
27
Person 9 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) currently responsible for most of
the basic needs of any grandchild(ren) under the
age of 18 who live(s) in this house or apartment?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 27a
No, never served in the military – SKIP to
question 28a
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) ever served on
active duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty does
not include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pn<¤
Form D-2(E)SUPP AS
797727
(1-21-2009)
Page 27 Solid black
D-2(E)SUPP AS, Page 27, Pantone Cyan (10%, 50% & 100%)
28
Person 9 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pn=¤
Form D-2(E)SUPP AS
797728
(1-21-2009)
Page 28 Solid black
D-2(E)SUPP AS, Page 28, Pantone Cyan (10%, 50% & 100%)
29
Person 9 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
For whom did (you/...) work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual,
for wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business
or farm?
§pn>¤
Form D-2(E)SUPP AS
797729
(1-21-2009)
Page 29 Solid black
D-2(E)SUPP AS, Page 29, Pantone Cyan (10%, 50% & 100%)
30
Person 9 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
report, if possible, the appropriate share for
each person; otherwise, report the whole
amount for only one person (and mark ✗ the "No"
box for the other person) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pn?¤
Form D-2(E)SUPP AS
797730
(1-21-2009)
Page 30 Solid black
D-2(E)SUPP AS, Page 30, Pantone Cyan (10%, 50% & 100%)
31
Person 9 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on form D-2(E)AS. If the number of people
is more than nine, continue on the next page. If not,
SKIP to the "Respondent Information" block on page
42 of form D-2(E)AS.
§pn@¤
Form D-2(E)SUPP AS
797731
(1-21-2009)
Page 31 Solid black
D-2(E)SUPP AS, Page 31, Pantone Cyan (10%, 50% & 100%)
32
Person 10
6. Print the name of Person 5 from page 2.
First Name
MI
11a. Where was (your/...’s) mother born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
Last Name
7. Where (were you/was ...) born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.
b. Where was (your/...’s) father born? Print the
name of the island (village in American Samoa),
U.S. state, commonwealth, territory, or foreign country.
12.
8. (Show Card C.) (Are you/Is ...) a CITIZEN or
NATIONAL of the United States?
Yes, born in this Area – SKIP to question 11a
Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent resident)
No, not a U.S. citizen or national (temporary resident)
9. When did (you/...) come to this Area to stay? If
(you have/... has) entered the Area more than
once, what is the latest year?
Print numbers in boxes.
Year
10. (Show Card D.) What was (your/...’s) MAIN reason
for moving to this Area? Mark ✗ ONE box.
Employment
Military
Subsistence activities
Missionary activities
Moved with spouse or parent
To attend school
Medical
Housing
Other
(Show Card E.) (Are you/Is ...) a dependent of an
active-duty or retired member of the Armed
Forces of the United States or of the full-time
military Reserves or National Guard? Active
duty does NOT include training for the
military Reserves or National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed Forces
Reserve
No
13a. At any time since February 1, 2010, (have
you/has ...) attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree. If
"Yes," ASK – Was it public or private?
No, has not attended since February 1 – SKIP to
question 14
Yes, public school, public college
Yes, private school, private college, home school
b. What grade or level (were you/was ...)
attending? Mark ✗ ONE box.
Pre-kindergarten
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)
§pnA¤
Form D-2(E)SUPP AS
797732
(1-21-2009)
Page 32 Solid black
D-2(E)SUPP AS, Page 32, Pantone Cyan (10%, 50% & 100%)
33
Person 10 – Continued
14.
(Show Card F.) What is the highest degree or
level of school (you have/... has) COMPLETED?
Mark ✗ ONE box. If currently enrolled, mark the previous
grade or highest degree received.
16c. (Do you/Does ...) speak this language at home
more frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English
NO SCHOOLING COMPLETED
No schooling completed
PRE-KINDERGARTEN THROUGH GRADE 12
Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA
17a. Did (you/...) live in this house or apartment
1 year ago (on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, this house – SKIP to question 18
No, different house
b. Where did (you/...) live 1 year ago?
HIGH SCHOOL GRADUATE
What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
If outside this Area, print the answer below and SKIP
to question 18.
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college
credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
15.
(Have you/Has ...) completed the requirements
for a vocational training program at a trade
school, business school, hospital, some other
kind of school for occupational training, or place
of work? Do not include academic college
courses. If "Yes," ASK – Was training received in
this area?
No
Yes, in this Area
Yes, not in this Area
16a. (Do you/Does ...) speak a language other
than English at home?
Yes
No – SKIP to question 17a
c. What is the name of the city, town, or village?
18.
(Show Card G.) (Are you/Is ...) CURRENTLY
covered by any of the following types of
health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in
items a–h.
a. Insurance through a current or former
employer or union (of this person or
another family member) . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by this person or
another family member) . . . . . . . . . . .
Yes No
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . .
e. TRICARE or other military health care
.
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Local medical programs for indigents . .
h. Any other type of health insurance or
health coverage plan – Specify
b. What is this language?
(For example: Chamorro, Samoan, Carolinian, Tongan)
§pnB¤
Form D-2(E)SUPP AS
797733
(1-21-2009)
Page 33 Solid black
D-2(E)SUPP AS, Page 33, Pantone Cyan (10%, 50% & 100%)
34
Person 10 – Continued
19a. (Are you/Is ...) deaf or (do you/does ...) have
serious difficulty hearing?
Yes
No
b. (Are you/Is ...) blind or (do you/does ...) have
serious difficulty seeing even when wearing
glasses?
Yes
No
Ask questions 20a–20c if this person is 5 years old or
over. Otherwise, SKIP to question 50.
20a. Because of a physical, mental, or emotional
condition, (do you/does ...) have serious
difficulty concentrating, remembering, or
making decisions?
24a. (Do you/Does ...) have any of (your/his/her) own
grandchildren under the age of 18 living in this
house or apartment?
Yes
No – SKIP to question 25
b. (Are you/Is ...) currently responsible for most of
the basic needs of any grandchild(ren) under the
age of 18 who live(s) in this house or apartment?
Yes
No – SKIP to question 25
c. How long (have you/has ...) been responsible
for the(se) grandchild(ren)? If (you are/... is)
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom (you have/... has) been
responsible for the longest period of time.
Yes
No
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
b. (Do you/Does ...) have serious difficulty walking
or climbing stairs?
Yes
No
25.
c. (Do you/Does ...) have difficulty dressing or
bathing?
Yes
No
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 27a
No, never served in the military – SKIP to
question 28a
Ask question 21 if this person is 15 years old or over.
Otherwise, SKIP to question 50.
21.
Because of a physical, mental, or emotional
condition, (do you/does ...) have difficulty
doing errands alone such as visiting a
doctor’s office or shopping?
Yes
No
22.
What is (your/...’s) marital status?
Now married
Widowed
Divorced
Separated
Never married
23.
If this person is female, ASK – How many babies
(have you/has she) ever had, not counting
stillbirths? Do not count stepchildren or
children (you have/she has) adopted.
None OR Number of children
(Show Card H.) (Have you/Has ...) ever served on
active duty in the U.S. Armed Forces, military
Reserves, or National Guard? Active duty does
not include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
26.
(Show Card I.) When did (you/...) serve on active
duty in the U.S. Armed Forces? Mark ✗ a box for
EACH period in which this person served, even if just for
part of the period. After each response, ASK – Any other
time?
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier
§pnC¤
Form D-2(E)SUPP AS
797734
(1-21-2009)
Page 34 Solid black
D-2(E)SUPP AS, Page 34, Pantone Cyan (10%, 50% & 100%)
35
Person 10 – Continued
27a. (Do you/Does ...) have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
30.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 38
Other method
b. What is (your/...’s) service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
28a. LAST WEEK, did (you/...) work for pay at a job (or
business)? If "Yes," ASK – Did (you/...) do
subsistence activity last week, such as fishing,
growing crops, etc., NOT primarily for
commercial purposes? Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 29
Yes, worked for pay AND did subsistence
activity – SKIP to question 29
No, did NOT work for pay at a job or business
(or was retired)
b. LAST WEEK, did (you/...) do ANY work for pay,
even for as little as one hour? Which of the
following categories describes (your/...’s)
situation LAST WEEK? Mark ✗ ONE box.
Worked for pay; did NO subsistence activity
Worked for pay AND did subsistence activity
Did NOT work for pay; did subsistence
activity – SKIP to question 34a
Did NOT work for pay; did NO
subsistence activity – SKIP to question 34a
29.
At what location did (you/...) work LAST WEEK?
Do not include subsistence activity. If this person
worked at more than one location, print where he or she
worked most last week.
a. What is the name of the island, U.S. state,
commonwealth, territory, or foreign country?
b. What is the name of the city, town, or village?
(Show Card J.) How did (you/...) usually get to work
LAST WEEK? Do not include transportation to
subsistence activity. If this person usually used more
than one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Ask question 31 if this person answered "Car, truck, or private
van/bus" in question 30. Otherwise, SKIP to question 32.
31.
How many people, including (yourself/...), usually
rode to work in the car, truck, or private van/bus
LAST WEEK?
Person(s)
32.
What time did (you/...) usually leave home to
go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
33.
How many minutes did it usually take (you/...) to
get from home to work LAST WEEK?
Minutes
Ask questions 34–37 if this person did NOT work last week.
Otherwise, SKIP to question 38.
34a. LAST WEEK, (were you/was ...) on layoff
from a job?
Yes – SKIP to question 34c
No
b. LAST WEEK, (were you/was ...) TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35
c. (Have you/Has ...) been informed that (you/he/she)
will be recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 36
No
§pnD¤
Form D-2(E)SUPP AS
797735
(1-21-2009)
Page 35 Solid black
D-2(E)SUPP AS, Page 35, Pantone Cyan (10%, 50% & 100%)
36
Person 10 – Continued
35.
During the LAST 4 WEEKS, (have you/has ...)
been ACTIVELY looking for work?
39.
Yes
No – SKIP to question 37
36.
For whom did (you/...) work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other employer
LAST WEEK, could (you/...) have started a job if
offered one, or returned to work if recalled? If "No,"
ASK – Was this because of a temporary illness or
for some other reason?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
37.
When did (you/...) last work, even for a few
days? Do not include subsistence activity.
40.
What kind of business or industry was this?
Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)
41.
Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?
42.
What kind of work (were you/was ...) doing?
(For example: registered nurse, machine repairer,
watchmaker, secretary, accountant)
43.
What were (your/...’s) most important
activities or duties? (For example: patient care,
repairing machinery, making watches, typing and
filing, reconciling financial records)
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 47
1999 or earlier – SKIP to question 47
Never worked; or did subsistence only – SKIP to
question 47
38–43. CURRENT OR MOST RECENT JOB
ACTIVITY
Describe clearly (your/...’s) chief job activity or
business last week. If (you/...) had more than
one job, describe the one at which (you/...)
worked the most hours. If (you/...) had no job
or business last week, give information for
(your/...’s) last job or business since 2005.
38.
(Show Card K.) (Were you/Was ...) – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual,
for wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business
or farm?
§pnE¤
Form D-2(E)SUPP AS
797736
(1-21-2009)
Page 36 Solid black
D-2(E)SUPP AS, Page 36, Pantone Cyan (10%, 50% & 100%)
37
Person 10 – Continued
44.
LAST YEAR, 2009, did (you/...) work at a job or
business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 47
47b. Did (you/...) receive any self-employment
income from own nonfarm businesses or farm
businesses, including proprietorships and
partnerships in 2009?
Yes – What was the NET income after business
expenses?
45a. During 2009 (all 52 weeks), did (you/...) work
50 or more weeks? Count paid time off as work.
Do not include subsistence activity.
Yes – SKIP to question 46
No
$
,
Loss
.00
No
b. How many weeks DID (you/...) work, even for a
few hours, including paid vacation, paid sick
leave, and military service? Do not include
subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less
46.
Annual amount – Dollars
c. Did (you/...) receive any interest, dividends, net
rental income, royalty income, or income from
estates and trusts in 2009? Report even small
amounts credited to an account.
Yes – What was the amount?
Annual amount – Dollars
$
,
Loss
.00
No
d. Did (you/...) receive any Social Security or
Railroad Retirement in 2009?
During 2009, in the WEEKS WORKED, how
many hours did (you/...) usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
47.
The next set of questions is about each income
source (you/...) received during 2009. If the net
income was a loss, please give the dollar
amount of the loss. For income received jointly,
report, if possible, the appropriate share for
each person; otherwise, report the whole
amount for only one person (and mark ✗ the "No"
box for the other person) . If the exact amount is
not known, please give your best estimate. If
net income is a loss, mark ✗ the "Loss" box next to the
dollar amount.
a. Did (you/...) receive any wages, salary,
commissions, bonuses, or tips in 2009?
Yes – What was the amount from all jobs before
deductions for taxes, bonds, dues, or
other items?
e. Did (you/...) receive any public assistance or
welfare payments from the state or local welfare
office, including Supplemental Security Income
(SSI) in 2009?
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
f. Did (you/...) receive any retirement, survivor, or
disability pensions in 2009? Do NOT include
Social Security.
Yes – What was the amount?
Annual amount – Dollars
Annual amount – Dollars
$
,
$
.00
,
.00
No
No
§pnF¤
Form D-2(E)SUPP AS
797737
(1-21-2009)
Page 37 Solid black
D-2(E)SUPP AS, Page 37, Pantone Cyan (10%, 50% & 100%)
38
Person 10 – Continued
47g. Did (you/...) receive any remittances in 2009?
Include money from relatives outside the
household or in the military.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
h. Did (you/...) receive any other sources of income
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support, or
alimony in 2009? Do NOT include lump-sum
payments such as money from an inheritance or
sale of a home.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
Do not ask question 48 if questions 47a-47h are completed.
Instead, sum these entries and subtract any losses. Enter the
amount below. If the total amount was a loss, mark ✗ the "Loss"
box next to the dollar amount.
48.
What was (your/...’s) total income during 2009?
Annual amount – Dollars
None OR
49.
$
,
Loss
.00
During 2009, did (you/...) GIVE or SEND
money TO relatives or friends living outside
of this Area? Do not include charitable
contributions or money given to charitable
organizations. If exact amount is not known,
please give best estimate.
Yes – What was the amount?
Annual amount – Dollars
$
,
.00
No
50.
Refer to S5 on form D-2(E)AS. If the number of people
is more than 10, go to the next form D-2(E)SUPP AS.
If not, SKIP to the "Respondent Information" block on
page 39 of form D-2(E)AS.
§pnG¤
Form D-2(E)SUPP AS
797738
(1-21-2009)
Page 38 Solid black
D-2(E)SUPP AS, Page 38, Pantone Cyan (10%, 50% & 100%)
| File Type | application/pdf |
| File Modified | 2009-01-29 |
| File Created | 2009-01-29 |