D-20 VI Individual Census Report, U.S. Virgin Islands

DRAFT #3 (1-21-2009)

Individual
Census
Report

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Use a blue or black pen.

Start here
1.

4. What is your telephone number? We may call
you if we don’t understand an answer.
Area Code + Number

-

What is your name? Print name below.
Last Name

First Name

-

5. What is your sex? Mark ✗ ONE box.
Male
Female

MI

2. Do you live or stay in this facility MOST OF
THE TIME?

6. What is your age and what is your date of
birth? Please report babies as age 0 when the child
is less than 1 year old.
Age on April 1, 2010

Yes – SKIP to question 4
No

3.

Print numbers in boxes.
Month
Day
Year of birth

What is the address of the place where you
live or stay MOST OF THE TIME?
House number

➔
Street or road name

Estate name

Plot number

House number

NOTE: Please answer BOTH Question 7
about Hispanic origin and Question 8 about
race. For this census, Hispanic origins are
not races.

7. Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Puerto Rican
Yes, Dominican
Yes, Mexican, Mexican Am., Chicano
Yes, another Hispanic, Latino, or Spanish origin –
Print origin, for example, Argentinean, Colombian,
Cuban, Nicaraguan, Salvadoran, Spaniard, and
so on.

Physical Landmark/Other Identifying Information

Island

6.
ZIP Code

OMB No. 0000-0000: Approval Expires 00/00/0000

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8. What is your race? Mark ✗ one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native – Print name of
enrolled or principal tribe.

Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – Print race, for example, Hmong,
Laotian, Thai, Pakistani, Cambodian, and so on.

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Print race, for example,
Fijian, Tongan, and so on.

Some other race – Print race.

11.

When did you come to the U.S. Virgin
Islands to stay? If you have entered the
U.S. Virgin Islands more than once, what
is the latest year?
Print numbers in boxes.
Year

12a. Where was your mother born? Print St. Croix,
St. John, or St. Thomas if in the U.S. Virgin Islands,
or the name of the U.S. state, commonwealth,
territory, or foreign country.

b. Where was your father born? Print St. Croix,
St. John, or St. Thomas if in the U.S. Virgin Islands,
or the name of the U.S. state, commonwealth,
territory, or foreign country.

13a. At any time since February 1, 2010, have
you attended school or college? Include
only nursery school or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, have not attended since February 1 – SKIP
to question 16
Yes, public school, public college
Yes, private school, private college, home school

9.

Where were you born? Print St. Croix, St. John,
or St. Thomas if in the U.S. Virgin Islands, or the
name of the U.S. state, commonwealth, territory, or
foreign country.

10. Are you a CITIZEN of the United States?
Yes, born in the U.S. Virgin Islands – SKIP to
question 14a
Yes, born in the United States, Puerto Rico, Guam,
or Northern Mariana Islands
Yes, born abroad of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen (permanent resident)
No, not a U.S. citizen (temporary resident)

b. What grade or level were you attending?
Mark ✗ ONE box.
Nursery school, preschool
Kindergarten
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
Graduate or professional school beyond a
bachelor’s degree (for example, MA or PhD
program or medical or law school)

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14. What is the highest degree or level of
school you have COMPLETED? Mark ✗
ONE box. If currently enrolled, mark the previous
grade or highest degree received.

17a. Did you live at this address 1 year ago
(on April 1, 2009)?
Person is under 1 year old – SKIP to question 18
Yes, at this address – SKIP to question 18
No, at a different address

NO SCHOOLING COMPLETED
No schooling completed

b. Where did you live 1 year ago?

NURSERY SCHOOL OR PRESCHOOL
THROUGH GRADE 12

What is the name of the island in the U.S.
Virgin Islands, or the name of the U.S.
state, commonwealth, territory, or foreign
country?

Nursery school, preschool
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA

c. What is the name of the city, town, or
village?

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
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)

18. Are you CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH
type of coverage in items a–g.
Yes No
a. Insurance through a current or former
employer or union (of yours or
another family member) . . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by you or
another family member) . . . . . . . . . . . .
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . . .

Doctorate degree (for example: PhD, EdD)

15. Have you 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.
No
Yes, in the U.S. Virgin Islands
Yes, not in the U.S. Virgin Islands

d. Medicaid, Medical Assistance, or any
kind of federal government assistance
plan for those with low incomes or a
disability . . . . . . . . . . . . . . . . . . . . . . .
e. TRICARE or other military health care . .
f. VA (including those who have ever
used or enrolled for VA health care) . . .
g. Any other type of health insurance or
health coverage plan – Specify

16a. Do you speak a language other than
English at home?
Yes
No – SKIP to question 17a

b. What is this language?

(For example: French, Spanish, Chinese, Italian)

c. How well do you speak English?
Very well
Well
Not well
Not at all

19a. Are you deaf or do you have serious
difficulty hearing?
Yes
No
b. Are you blind or do you have serious
difficulty seeing even when wearing
glasses?
Yes
No

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Answer questions 20a–c if you are 5 years old or over.
Otherwise, SKIP to question 49.
20a. Because of a physical, mental, or
emotional condition, do you have serious
difficulty concentrating, remembering, or
making decisions?

24c. How long have you been responsible for
the(se) grandchild(ren)? If you are financially
responsible for more than one grandchild, answer
the question for the grandchild for whom you have
been responsible for the longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

Yes
No

b. Do you have serious difficulty walking or
climbing stairs?

25.

Yes
No

c. Do you 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

Answer question 21 if you are 15 years old or over.
Otherwise, SKIP to question 49.
21.

Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No

22.

26.

What is your marital status?
Now married
Widowed
Divorced
Separated
Never married

23.

If you are female, how many babies have
you ever had, not counting stillbirths? Do
not count stepchildren or children you have
adopted.
None OR Number of children

24a. Do you have any of your own grandchildren
under the age of 18 living in this house,
apartment, dormitory, or institution?
Yes
No – SKIP to question 25

b. Are you currently responsible for most of
the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this
house, apartment, dormitory, or
institution?
Yes
No – SKIP to question 25

Have you ever served on active duty in
the U.S. Armed Forces, military Reserves,
or National Guard? Active duty does not
include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.

When did you serve on active duty in the
U.S. Armed Forces? Mark ✗ a box for EACH
period in which you served, even if just for part of
the period.
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

27a. Do you have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 28a
b. What is your service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

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28a. LAST WEEK, did you work for pay at a job
(or business)?

33.

Yes – SKIP to question 29
No, did NOT work (or retired)

b. LAST WEEK, did you do ANY work for pay,
even for as little as one hour?
Yes
No – SKIP to question 34a

How many minutes did it usually take you
to get from this address to work LAST
WEEK?
Minutes

Answer questions 34–37 if you did NOT work last week.
Otherwise, SKIP to question 38.

34a. LAST WEEK, were you on layoff from a job?

29. At what location did you work LAST WEEK?
If you worked at more than one location, print where
you worked most last week.

Yes – SKIP to question 34c
No

b. LAST WEEK, were you TEMPORARILY
absent from a job or business?

a. What is the name of the island in the U.S.
Virgin Islands, or name of the U.S. state,
commonwealth, territory, or foreign country?

Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 37
No – SKIP to question 35

b. What is the name of the city, town, or village?

c. Have you been informed that you will be
recalled to work within the next 6 months
OR been given a date to return to work?
30. How did you usually get to work LAST
WEEK? If you usually used more than one
method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Car, truck, or van
Bus (including Vitran or Vitran Plus)
Taxicab
Motorcycle
Safari or taxi bus
Ferryboat or water taxi
Plane or seaplane
Walked
Worked at home – SKIP to question 38
Other method

Answer question 31 if you marked "Car, truck, or van" in
question 30. Otherwise, SKIP to question 32.
31. How many people, including yourself,
usually rode to work in the car, truck, or
van LAST WEEK?
Person(s)

Yes – SKIP to question 36
No

35.

During the LAST 4 WEEKS, have you been
ACTIVELY looking for work?
Yes
No – SKIP to question 37

36.

LAST WEEK, could you have started a job if
offered one, or returned to work if recalled?
Yes, could have gone to work
No, 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?
2005 to 2010
2004 or earlier, or never worked – SKIP to
question 47

32. What time did you usually leave this address
to go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.

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38–43.

CURRENT OR MOST RECENT JOB
ACTIVITY

Describe clearly your chief job activity or
business last week. If you had more than one
job, describe the one at which you worked the
most hours. If you had no job or business last
week, give information for your last job or
business since 2005.

42. What kind of work were you doing?
(For example: registered nurse, personnel
manager, supervisor of order department,
secretary, accountant)

38. Were you – Mark ✗ ONE box.
An employee of a PRIVATE FOR-PROFIT
company or business or of an individual, for
wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local GOVERNMENT employee
(territorial, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

43. What were your most important activities
or duties? (For example: patient care, directing
hiring policies, supervising order clerks, typing and
filing, reconciling financial records)

Working WITHOUT PAY in family business or farm?

39. 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

44. LAST YEAR, 2009, did you work at a job
or business at any time?
Yes
No – SKIP to question 47

45a. During 2009 (all 52 weeks), did you work
50 or more weeks? Count paid time off as work.
Yes – SKIP to question 46
No

b. How many weeks DID you work, even for
a few hours, including paid vacation, paid
sick leave, and military service?
40. What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto repair shop, bank)

50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

46. During 2009, in the WEEKS WORKED, how
many hours did you usually work each
WEEK?
Usual hours worked each WEEK
41. Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?

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47.

INCOME IN 2009
Mark ✗ the "Yes" box for each income source
received during 2009, and enter the total amount
received during 2009 to a maximum of $999,999
($99,999 for questions 49d and 49e). Mark ✗ the
"No" box if the income source was not received.
If net income was a loss, enter the amount and
mark ✗ the "Loss" box next to the dollar amount.

a. Wages, salary, commissions, bonuses, or
tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Annual amount – Dollars
Yes
No

$

,

.00

47g. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support,
or alimony. Do NOT include lump-sum payments
such as money from an inheritance or sale of a home.
Annual amount – Dollars
Yes
No

$

,

.00

48. What was your total income during 2009?
Add entries in questions 47a–47g; subtract any
losses. If net income was a loss, enter the amount and
mark ✗ the "Loss" box next to the dollar amount.
Annual amount – Dollars
Loss
None OR

$

,

.00

b. Self-employment income from own
49. Please check this form to be sure you have
nonfarm businesses or farm businesses,
answered all the required questions
including proprietorships and partnerships.
completely.
Report NET income after business expenses.
Annual amount – Dollars
Loss
To return your form, please follow the
instructions on the envelope that the form
Yes
,
$
.00
came in.
No
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Annual amount – Dollars
Loss
Yes
No

$

,

.00

d. Social Security or Railroad Retirement.
Annual amount – Dollars
Yes
No

$

,

.00

e. Any public assistance or welfare payments
from the state or local welfare office,
including Supplemental Security Income
(SSI).
Annual amount – Dollars
Yes
No

$

,

.00

f. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Annual amount – Dollars
Yes
No

$

,

.00

Thank you for
completing this official
Census 2010 form.
The Census Bureau estimates that, on average, each
respondent will take 24 minutes to complete this form,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any aspect of the burden to: Paperwork
Reduction Project 0607-0000, U.S. Census Bureau,
4600 Silver Hill Road, AMSD-3K138, Washington, DC
20233. You may email comments to
[email protected]; use "Paperwork Project
0607-0000" as the subject.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management and
Budget.

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FOR OFFICE USE ONLY

FOROFFICE
OFFICE USE
ONLY
FOR
USE
ONLY
A. GQ ID

B. LCO

H. Add

C. County

I. GQ Type

D. Block

E. AA

F. Map Spot

G. PN

J.

Y N

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