D-21 PI Military Census Report, Pacific Islands

DRAFT #3 (1-21-2009)

Pacific Islands

Military
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 name? Print name below.
Last Name

First Name

Print numbers in boxes.
Month
Day
Year of birth
MI

5.
2.

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

What is your ethnic origin or race?

What is the full name and address of the
place (barrack/dormitory, disciplinary
barrack/jail, military treatment facility)
where you are assigned?
Please complete all that apply.
(For example: Chamorro, Samoan, White, Black,
Carolinian, Filipino, Japanese, Korean, Palauan,
Tongan, and so on.)

Military installation or Base name

6.

Where were you born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

7.

Are you a CITIZEN or NATIONAL of the
United States?

Barrack or dormitory name

Barrack or dormitory number

Street number

Street name

3. What is your sex? Mark ✗ ONE box.

Yes, born in this area of current residence
(American Samoa, Northern Mariana Islands,
Guam) – SKIP to question 10a
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)

8. When did you come to this area of current
residence to stay? If you have entered the
area more than once, what is the latest year?
Print numbers in boxes.
Year

Male
Female

OMB No. 0607-0806: Approval Expires 12/31/2010

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9.

Form D-21 PI

What was your 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

10a. Where was your mother born? Print the name
of the island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

12.

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.
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
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential

b. Where was your father born? Print the name of
the island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

11a. At any time since February 1, 2010, have
you attended school or college? Include
only 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 12
Yes, public school, public college
Yes, private school, private college, home school

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)

13. Have you completed the requirements for a
vocational training program at a trade
school, business school, hospital, some
other kind of school for occupational
Grade 1 through 12 –
training, or place of work? Do not include
Specify grade 1–12
academic college courses.
College undergraduate years (freshman to senior)
No
Graduate or professional school beyond a
Yes, in this area
bachelor’s degree (for example, MA or PhD
program or medical or law school)
Yes, not in this area

b. What grade or level were you attending?
Mark ✗ ONE box.

14a. Do you speak a language other than
English at home?
Yes
No – SKIP to question 15a

b. What is this language?

(For example: Chamorro, Samoan, Carolinian, Tongan)

c. Do you speak this language at home more
frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Do not speak English

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15a. Did you live at the address reported in
question 2 one year ago (on April 1, 2009)?
Yes – SKIP to question 16
No

18a. Because of a physical, mental, or
emotional condition, do you have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

b. Where did you live 1 year ago?

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

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

Yes
No

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

c. Do you have difficulty dressing or bathing?
Yes
No

16. Are you CURRENTLY covered by any of the 19.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH
type of coverage in items a–h.
Yes No
a. Insurance through a current or former
employer or union (of yours or
another family member) . . . . . . . . . . . .
20.
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 . . . . . . . .
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) . . . .

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

21. 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

g. Local medical programs for indigents . . .
h. Any other type of health insurance or
health coverage plan – Specify

17a. 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

22. 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. If the only active duty was for training
in the military Reserves or the National
Guard, mark ✗ this box
and then SKIP to question 23a.
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

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23a. Do you have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
No – SKIP to question 24a

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

24a. LAST WEEK, did you work for pay at a job
(or business)? Do not include subsistence activity.
Mark ✗ the "Yes" box if you worked at all or were in
training, at your duty station, or elsewhere.
Yes – SKIP to question 25
No

b. LAST WEEK, did you do ANY work for pay,
even for as little as an hour? Do not include
subsistence activity.

Answer question 27 if you marked "Car, truck, or private
van/bus" in question 26. Otherwise, SKIP to question 28.

27. How many people, including yourself,
usually rode to work in the car, truck, or
private van/bus LAST WEEK?
Person(s)

28. What time did you usually leave home to go
to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.
29. How many minutes did it usually take you
to get from home to work LAST WEEK?
Minutes

30. What is your branch of service?
Air Force
Army
Marine Corps
Navy
Coast Guard
Not in U.S. Armed Forces – Describe the kind of
business of your employer.

Yes
No – SKIP to question 30

25. At what location did you work LAST WEEK?
Do not include subsistence activity. If you worked at
more than one location, print where you 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?

26.

How did you usually get to work LAST
WEEK? Do not include transportation to
subsistence activity. 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.

31a. What kind of work are you doing? (For
example: aircraft engine mechanic, electronic
technician, field artillery surveyor, sonar technician,
tactical intelligence officer)

Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 30
Other method

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31b. What are your most important activities
or duties? (For example: repair seaplanes,
research on electronic components, survey artillery
ranges, repair sonar equipment, edit intelligence
manuals)

c. What is your main job specialty? If you have
more than one specialty, list the one at which you
spend the most time.

32c. 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

d. 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

(1) Job Title

(2) Job Code
(AOC/MOS/NOBC/Rating/AFSC/Occ Fld)

33. 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.
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.

d. What is your paygrade? Enter the
two-character code. (For example: O-3, W-2, E-4)
Paygrade
–
32a. LAST YEAR, 2009, did you work at a job
or business, or were you on active-duty
military service, at any time? Do not include
subsistence activity.
Yes (worked or on active duty)
No – SKIP to question 33

b. 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 32d
No

a. Pay and allowances as a member of the U.S.
ARMED FORCES including special,
incentive, and bonus pay. Also, wages,
salaries, commissions, and tips from
CIVILIAN JOBS – Report total amount from all jobs
BEFORE DEDUCTIONS for taxes, bonds, dues, or
other items.
Annual amount – Dollars
Yes
No

$

,

.00

b. Self-employment income from own
nonfarm businesses or farm businesses,
including proprietorships and partnerships.
Report NET income after business expenses.
Annual amount – Dollars
Loss
Yes
No

$

,

.00

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

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33d. Any other sources of income received
regularly such as Social Security, public
assistance or welfare 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

34.

$

.00

What was your total income in 2009? Add
entries in questions 33a–33d; subtract any losses. If
net income was a loss, mark ✗ the "Loss" box next
to the amount.
Annual amount – Dollars
Loss
None OR

35.

,

$

,

.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 0607-0806, U.S. Census Bureau,
4600 Silver Hill Road, AMSD-3K138, Washington, DC
20233. You may email comments to
[email protected]; use "Paperwork Project
0607-0806" 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.

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.
Annual amount – Dollars
Yes
No

36.

$

,

.00

Please check this form to be sure you have
answered all the required questions
completely. Please return your completed
form to your Census unit representative.

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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. JIC

Y N

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