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DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
Please complete this form and return
it as soon as possible after receiving
it in the mail.
This form asks for information about
the people who are living or staying at
the address on the mailing label and
about the house, apartment, or mobile
home located at the address on the
mailing label.
Start Here
➜
Please print today’s date.
Year
Month Day
➜
Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name
First Name
MI
Area Code + Number
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
—
➜
How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people
➜
Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede pedir un cuestionario en
español o completar su entrevista por teléfono
con un entrevistador que habla español.
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/
USCENSUSBUREAU
ACS-1(2010)KFI
FORM
(05-14-2009)
OMB No. 0607-0810
§.4!-¤
ACS-1(2010)KFI, Page 1, Base (Black)
ACS-1(2010)KFI, Page 1, Green Pantone 354 (20 and 40%)
13190020
Person 1
Person 2
1 What is Person 2’s name?
(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1?
X
3
Person 1
4
Month
Day
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
6 What is Person 2’s race? Mark (X) one or more boxes.
What is Person 1’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Some other race – Print race.
2
Roomer or boarder
Stepson or stepdaughter
Age (in years)
Year of birth
Question 6 about race. For this survey, Hispanic origins are not races.
6
Adopted son or daughter
Male
Female
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Other relative
3 What is Person 2’s sex? Mark (X) ONE box.
What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Son-in-law or daughter-in-law
Biological son or daughter
Parent-in-law
What is Person 1’s sex? Mark (X) ONE box.
Male
Husband or wife
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Some other race – Print race.
§.4!5¤
ACS-1(2010)KFI, Page 2, Base (Black)
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13190038
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Other relative
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Male
Female
What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Question 6 about race. For this survey, Hispanic origins are not races.
Female
4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
6
2 How is this person related to Person 1? Mark (X) ONE box.
Son-in-law or daughter-in-law
Age (in years)
5
MI
Biological son or daughter
Male
4
First Name
Husband or wife
Parent-in-law
3
Last Name (Please print)
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 4 of Hispanic, Latino, or Spanish origin?
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
6 What is Person 4’s race? Mark (X) one or more boxes.
What is Person 3’s race? Mark (X) one or more boxes.
White
White
Black, African Am., or Negro
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Some other race – Print race.
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Some other race – Print race.
§.4!G¤
ACS-1(2010)KFI, Page 3, Base (Black)
3
ACS-1(2010)KFI, Page 3, Green Pantone 354 (20 and 40%)
13190046
Person 5
1
➜
What is Person 5’s name?
Last Name (Please print)
First Name
MI
If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.
Person 6
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
3
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Sex
Female
Month
Female
Day
Last Name (Please print)
First Name
MI
Year of birth
Sex
Male
Female
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Age (in years)
Person 8
What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Male
Is Person 5 of Hispanic, Latino, or Spanish origin?
Age (in years)
Person 9
Last Name (Please print)
First Name
MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Sex
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
Male
Female
Person 10
Last Name (Please print)
6
Age (in years)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Male
Female
Person 11
Last Name (Please print)
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on.
Sex
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Age (in years)
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race.
Sex
4
Male
Female
Age (in years)
§.4!O¤
ACS-1(2010)KFI, Page 4, Base (Black)
MI
ACS-1(2010)KFI, Page 4, Green Pantone 354 (20 and 40%)
MI
13190053
Housing
➜
1
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
8 Does this house, apartment, or mobile
Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.
home have –
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.
a. hot and cold running water?
4 How many acres is this house or
c. a bathtub or shower?
mobile home on?
Less than 1 acre ➔ SKIP to question 6
d. a sink with a faucet?
1 to 9.9 acres
e. a stove or range?
10 or more acres
f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.
5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
None
9 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
None
$5,000 to $9,999
1
$10,000 or more
2
About when was this building first built?
2000 or later – Specify year
3
6 Is there a business (such as a store or
4
barber shop) or a medical office on
this property?
5
6 or more
Yes
1990 to 1999
No
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
3
No
b. a flush toilet?
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
2
Yes
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
10 Which FUEL is used MOST for heating this
7 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms
house, apartment, or mobile home?
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
Year
b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would
list if this house, apartment, or mobile home
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
No fuel used
Number of bedrooms
§.4!V¤
ACS-1(2010)KFI, Page 5, Base (Black)
5
ACS-1(2010)KFI, Page 5, Green Pantone 354 (10, 20, 40 and 50%)
13190061
Housing (continued)
11 a. LAST MONTH, what was the cost
12 IN THE PAST 12 MONTHS, did anyone in
of electricity for this house,
apartment, or mobile home?
this household receive Food Stamps or
a Food Stamp benefit card? Include
government benefits from the Supplemental
Nutrition Assistance Program (SNAP).
Do NOT include WIC or the National School
Lunch Program.
Last month’s cost – Dollars
$
.00
,
OR
No
16 About how much do you think this
No charge or electricity not used
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
13 Is this house, apartment, or mobile home
part of a condominium?
Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.
Last month’s cost – Dollars
.00
,
OR
Monthly amount – Dollars
Included in rent or condominium fee
c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
$
$
,
.00
,
17 What are the annual real estate taxes on
THIS property?
.00
,
$
.00
,
OR
No
None
14 Is this house, apartment, or mobile home –
Mark (X) ONE box.
18 What is the annual payment for fire,
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Included in rent or condominium fee
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
No charge
Rented?
OR
Past 12 months’ cost – Dollars
$
None
.00
d. IN THE PAST 12 MONTHS, what was the
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
home? If you have lived here less than 12
months, estimate the cost.
Amount – Dollars
OR
Past 12 months’ cost – Dollars
,
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?
Annual amount – Dollars
Included in electricity payment
entered above
No charge or gas not used
$
Answer questions 16 – 20 if you or
someone else in this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E on
the next page.
Yes
Included in rent or condominium fee
$
C
Annual amount – Dollars
$
.00
,
OR
Occupied without payment of
rent? ➔ SKIP to C
B
hazard, and flood insurance on THIS
property?
None
Answer questions 15a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 16.
.00
,
15 a. What is the monthly rent for this
OR
Included in rent or condominium fee
No charge or these fuels not used
house, apartment, or mobile home?
Monthly amount – Dollars
$
,
.00
b. Does the monthly rent include any
meals?
Yes
No
6
§.4!^¤
ACS-1(2010)KFI, Page 6, Base (Black)
ACS-1(2010)KFI, Page 6, Green Pantone 354 (10, 20, 40 and 50%)
13190079
Housing (continued)
19 a. Do you or any member of this
20 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
E
Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home
equity loan
No ➔ SKIP to D
No ➔ SKIP to question 20a
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?
Monthly amount – Dollars
Monthly amount – Dollars
$
,
.00
$
OR
OR
No regular payment required ➔ SKIP to
question 20a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
.00
,
No regular payment required
D
Answer question 21 if this is a MOBILE
HOME. Otherwise, SKIP to E .
21 What are the total annual costs for
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance
personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
Annual costs – Dollars
$
,
.00
§.4!p¤
ACS-1(2010)KFI, Page 7, Base (Black)
7
ACS-1(2010)KFI, Page 7, Green Pantone 354 (10, 20, 40 and 50%)
13190087
Person 1
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
14 a. Does this person speak a language other than
English at home?
Yes
b. What is this language?
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Very well
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Not well
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
Not at all
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)
No, not a U.S. citizen
Doctorate degree (for example: PhD, EdD)
When did this person come to live in the
United States? Print numbers in boxes.
Year
F
10 a. At any time IN THE LAST 3 MONTHS, has this
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
12 This question focuses on this person’s
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Kindergarten
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Yes, public school, public college
Nursery school, preschool
Well
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
8
13 What is this person’s ancestry or ethnic origin?
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Address (Number and street name)
Name of city, town, or post office
Name of U.S. county or municipio in
Puerto Rico
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico
ZIP Code
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)
8
§.4!x¤
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13190095
Person 1 (continued)
H
16 Is this person CURRENTLY covered by any of the
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Widowed
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
e. TRICARE or other military health care
Separated
Yes, now on active duty
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
Yes, on active duty during
the last 12 months, but not now
g. Indian Health Service
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
a. Married?
No, training for Reserves or National Guard
only ➔ SKIP to question 28a
b. Widowed?
No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
17 a. Is this person deaf or does he/she have
Yes, on active duty in the past, but not
during the last 12 months
No
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
serious difficulty hearing?
in which this person served, even if just for part of the
period.
Once
Yes
Two times
September 2001 or later
No
Three or more times
August 1990 to August 2001 (including
Persian Gulf War)
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
I
February 1955 to February 1961
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in
the past 12 months?
November 1941 or earlier
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent 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
Yes
No
No ➔ SKIP to question 26
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s 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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Person 1 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
38 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 47
39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 40
c. Is the work location inside the limits of that
city or town?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 35c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 37
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
Taxicab
10
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13190111
Person 1 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. 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 the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
43 What kind of business or industry was this?
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 2 on the
next page. If only 1 person is listed on page 2,
SKIP to page 28 for mailing instructions.
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13190129
Person 2
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
14 a. Does this person speak a language other than
English at home?
Yes
b. What is this language?
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Very well
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Not well
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
Not at all
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)
No, not a U.S. citizen
Doctorate degree (for example: PhD, EdD)
When did this person come to live in the
United States? Print numbers in boxes.
Year
F
10 a. At any time IN THE LAST 3 MONTHS, has this
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Well
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
8
13 What is this person’s ancestry or ethnic origin?
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
Kindergarten
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Address (Number and street name)
Name of city, town, or post office
Name of U.S. county or municipio in
Puerto Rico
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico
ZIP Code
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)
12
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13190137
Person 2 (continued)
H
16 Is this person CURRENTLY covered by any of the
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Widowed
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
e. TRICARE or other military health care
Separated
Yes, now on active duty
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
Yes, on active duty during
the last 12 months, but not now
g. Indian Health Service
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
a. Married?
No, training for Reserves or National Guard
only ➔ SKIP to question 28a
b. Widowed?
No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
17 a. Is this person deaf or does he/she have
Yes, on active duty in the past, but not
during the last 12 months
No
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
serious difficulty hearing?
in which this person served, even if just for part of the
period.
Once
Yes
Two times
September 2001 or later
No
Three or more times
August 1990 to August 2001 (including
Persian Gulf War)
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
I
February 1955 to February 1961
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in
the past 12 months?
November 1941 or earlier
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent 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
Yes
No
No ➔ SKIP to question 26
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s 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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13190145
Person 2 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
38 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 47
39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 40
c. Is the work location inside the limits of that
city or town?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 35c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 37
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
Taxicab
14
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13190152
Person 2 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. 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 the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
43 What kind of business or industry was this?
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 3 on the
next page. If only 2 people are listed on page 2,
SKIP to page 28 for mailing instructions.
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13190160
Person 3
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
14 a. Does this person speak a language other than
English at home?
Yes
b. What is this language?
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Very well
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Not well
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
Not at all
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)
No, not a U.S. citizen
Doctorate degree (for example: PhD, EdD)
When did this person come to live in the
United States? Print numbers in boxes.
Year
F
10 a. At any time IN THE LAST 3 MONTHS, has this
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Well
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
8
13 What is this person’s ancestry or ethnic origin?
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
Kindergarten
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Address (Number and street name)
Name of city, town, or post office
Name of U.S. county or municipio in
Puerto Rico
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico
ZIP Code
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)
16
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13190178
Person 3 (continued)
H
16 Is this person CURRENTLY covered by any of the
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Widowed
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
e. TRICARE or other military health care
Separated
Yes, now on active duty
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
Yes, on active duty during
the last 12 months, but not now
g. Indian Health Service
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
a. Married?
No, training for Reserves or National Guard
only ➔ SKIP to question 28a
b. Widowed?
No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
17 a. Is this person deaf or does he/she have
Yes, on active duty in the past, but not
during the last 12 months
No
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
serious difficulty hearing?
in which this person served, even if just for part of the
period.
Once
Yes
Two times
September 2001 or later
No
Three or more times
August 1990 to August 2001 (including
Persian Gulf War)
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
I
February 1955 to February 1961
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in
the past 12 months?
November 1941 or earlier
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent 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
Yes
No
No ➔ SKIP to question 26
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s 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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13190186
Person 3 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
38 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 47
39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 40
c. Is the work location inside the limits of that
city or town?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 35c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 37
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
Taxicab
18
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Person 3 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. 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 the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
43 What kind of business or industry was this?
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 4 on the
next page. If only 3 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.
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Person 4
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 4 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
14 a. Does this person speak a language other than
English at home?
Yes
b. What is this language?
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Very well
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Not well
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
Not at all
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)
No, not a U.S. citizen
Doctorate degree (for example: PhD, EdD)
When did this person come to live in the
United States? Print numbers in boxes.
Year
F
10 a. At any time IN THE LAST 3 MONTHS, has this
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Well
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
8
13 What is this person’s ancestry or ethnic origin?
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
Kindergarten
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Address (Number and street name)
Name of city, town, or post office
Name of U.S. county or municipio in
Puerto Rico
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico
ZIP Code
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)
20
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13190210
Person 4 (continued)
H
16 Is this person CURRENTLY covered by any of the
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Widowed
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
e. TRICARE or other military health care
Separated
Yes, now on active duty
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
Yes, on active duty during
the last 12 months, but not now
g. Indian Health Service
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
a. Married?
No, training for Reserves or National Guard
only ➔ SKIP to question 28a
b. Widowed?
No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
17 a. Is this person deaf or does he/she have
Yes, on active duty in the past, but not
during the last 12 months
No
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
serious difficulty hearing?
in which this person served, even if just for part of the
period.
Once
Yes
Two times
September 2001 or later
No
Three or more times
August 1990 to August 2001 (including
Persian Gulf War)
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
I
February 1955 to February 1961
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in
the past 12 months?
November 1941 or earlier
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent 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
Yes
No
No ➔ SKIP to question 26
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s 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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Person 4 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
38 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 47
39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 40
c. Is the work location inside the limits of that
city or town?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 35c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 37
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
Taxicab
22
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Person 4 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. 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 the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
43 What kind of business or industry was this?
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Continue with the questions for Person 5 on the
next page. If only 4 people are listed on pages 2
and 3, SKIP to page 28 for mailing instructions.
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Person 5
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 5 from page 4,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
First Name
MI
Nursery school
Kindergarten
7
Grade 1 through 11 – Specify
grade 1 – 11
Where was this person born?
In the United States – Print name of state.
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
14 a. Does this person speak a language other than
English at home?
Yes
b. What is this language?
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States?
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Yes, born in the United States ➔ SKIP to 10a
Some college credit, but less than 1 year of
college credit
Very well
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
1 or more years of college credit, no degree
Not well
Yes, born abroad of U.S. citizen parent
or parents
Associate’s degree (for example: AA, AS)
Not at all
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)
No, not a U.S. citizen
Doctorate degree (for example: PhD, EdD)
When did this person come to live in the
United States? Print numbers in boxes.
Year
F
10 a. At any time IN THE LAST 3 MONTHS, has this
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
person attended school or college? Include
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
No, has not attended in the last 3
months ➔ SKIP to question 11
Well
Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year
of naturalization
9
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
No ➔ SKIP to question 15a
12th grade – NO DIPLOMA
8
13 What is this person’s ancestry or ethnic origin?
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
12 This question focuses on this person’s
Yes, public school, public college
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
Kindergarten
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
Address (Number and street name)
Name of city, town, or post office
Name of U.S. county or municipio in
Puerto Rico
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico
ZIP Code
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)
24
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Person 5 (continued)
H
16 Is this person CURRENTLY covered by any of the
c. How long has this grandparent been
responsible for the(se) grandchild(ren)?
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities
20 What is this person’s marital status?
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years
26 Has this person ever served on active duty in the
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Now married
U.S. Armed Forces, military Reserves, or National
Guard? Active duty does not include training for the
Widowed
Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
e. TRICARE or other military health care
Separated
Yes, now on active duty
f. VA (including those who have ever
used or enrolled for VA health care)
Never married ➔ SKIP to I
Yes, on active duty during
the last 12 months, but not now
g. Indian Health Service
Divorced
21 In the PAST 12 MONTHS did this person get –
Yes
h. Any other type of health insurance
or health coverage plan – Specify
a. Married?
No, training for Reserves or National Guard
only ➔ SKIP to question 28a
b. Widowed?
No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
17 a. Is this person deaf or does he/she have
Yes, on active duty in the past, but not
during the last 12 months
No
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
serious difficulty hearing?
in which this person served, even if just for part of the
period.
Once
Yes
Two times
September 2001 or later
No
Three or more times
August 1990 to August 2001 (including
Persian Gulf War)
b. Is this person blind or does he/she have
23 In what year did this person last get married?
serious difficulty seeing even when wearing
glasses?
Year
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
I
February 1955 to February 1961
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in
the past 12 months?
November 1941 or earlier
28 a. Does this person have a VA service-connected
Yes
disability rating?
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
b. Is this grandparent 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
Yes
No
No ➔ SKIP to question 26
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a
b. What is this person’s 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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Person 5 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
WEEK? If this person worked at more than one
Hour
location, print where he or she worked most
last week.
:
a. Address (Number and street name)
38 When did this person last work, even for a few
Minute
a.m.
p.m.
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
Over 5 years ago or never worked ➔ SKIP to
question 47
39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
b. Name of city, town, or post office
Yes ➔ SKIP to question 40
c. Is the work location inside the limits of that
city or town?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
Yes
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
No, outside the city/town limits
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
e. Name of U.S. state or foreign country
48 to 49 weeks
Yes ➔ SKIP to question 35c
40 to 47 weeks
No
27 to 39 weeks
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code
50 to 52 weeks
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
13 weeks or less
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
Usual hours worked each WEEK
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 37
Streetcar or trolley car
Walked
No
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39a
Ferryboat
Other method
Taxicab
26
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Person 5 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.
45 What kind of work was this person doing?
d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes ➔
No
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
Yes ➔
No
a local GOVERNMENT employee
(city, county, etc.)?
Mark (X) the "No" box to show types of income
NOT received.
a state GOVERNMENT employee?
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?
Yes ➔
No
Yes ➔
For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.
$
No
,
TOTAL AMOUNT for past
12 months
$
.00
,
TOTAL AMOUNT for past
12 months
$
No
.00
,
TOTAL AMOUNT for past
12 months
h. 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 the sale of a
home.
a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
$
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
TOTAL AMOUNT for past
12 months
activities or duties? (For example: patient care,
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
a Federal GOVERNMENT employee?
.00
,
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 Was this person –
Mark (X) ONE box.
$
.00
Yes ➔
TOTAL AMOUNT for past
12 months
$
.00
,
No
Name of company, business, or other employer
TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
48 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 47a
43 What kind of business or industry was this?
to 47h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
Yes ➔
$
No
,
.00
TOTAL AMOUNT for past
12 months
Loss
None OR $
No
$
,
,
.00
TOTAL AMOUNT for past
12 months
c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
,
.00
TOTAL AMOUNT for past
12 months
Loss
➜
Now continue with the mailing instructions
on page 28.
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Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Housing questions
• answered all Person questions for each person.
➜ Then...
• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.
For Census Bureau Use
POP
EDIT
EDIT CLERK
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 38 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2010)KFI (05-14-2009)
28
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| File Type | application/pdf |
| File Title | acs1p01_10.g |
| File Modified | 2009-06-24 |
| File Created | 2009-06-24 |