Various Demographic Pretesting Activities

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.
Month Day
Year

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 and 3 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(2011)KFI, Page 1, Base (Black)

ACS-1(2011)RELMAR (V4)

FORM
(10-28-2010) Draft 4

OMB No. 0607-0725
Approval Expires: 08/31/2013

ACS-1(2011)KFI, Page 1, Green Pantone 354 (20 and 40%)

Person 1

Person 2

(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.)

➜

If only one person lives here, SKIP to page 4.

1 What is Person 2’s name?
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

5

Month

Day

Year of birth

Opposite-sex unmarried partner

Son-in-law or daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

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.
Age (in years)

Month

Day

Year of birth

5 Where was this person born?

In the United States – Print name of state.

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

6 Is this person a citizen of the United States?

Is this person a citizen of the United States?

7

Parent-in-law

Male

Where was this person born?

6

Same-sex husband/wife/spouse

3 What is Person 2’s sex? Mark (X) ONE box.

Female

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)

Grandchild

Father or mother

What is Person 1’s sex? Mark (X) ONE box.
Male

Opposite-sex husband/wife/spouse

Yes, born in the United States – Continue with Person 2 in the
next column if there are 2 or more people. Otherwise, SKIP to page 4

Yes, born in the United States – Continue with Person 3 on page 3
if there are 3 or more people. Otherwise, SKIP to page 4

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

Yes, born abroad of U.S. citizen parent
or parents

Yes, born abroad of U.S. citizen parent
or parents

Yes, U.S. citizen by naturalization – Print year
of naturalization

Yes, U.S. citizen by naturalization – Print year
of naturalization

No, not a U.S. citizen

No, not a U.S. citizen

When did this person come to live in the
United States? Print numbers in boxes.
Year

7 When did this person come to live in the
United States? Print numbers in boxes.
Year

2
ACS-1(2011)KFI, Page 2, Base (Black)

ACS-1(2011)KFI, Page 2, Green Pantone 354 (20 and 40%)

Person 3
➜

If only two persons live here, SKIP to page 4.

1

What is Person 3’s name?

➜

If only three persons live here, SKIP to page 4.

1 What is Person 4’s name?

Last Name (Please print)

2

Person 4

First Name

MI

How is this person related to Person 1? Mark (X) ONE box.

Last Name (Please print)

First Name

MI

2 How is this person related to Person 1? Mark (X) ONE box.

Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex husband/wife/spouse

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex husband/wife/spouse

Parent-in-law

Opposite-sex unmarried partner

Son-in-law or daughter-in-law

Opposite-sex unmarried partner

Son-in-law or daughter-in-law

Same-sex unmarried partner

Other relative

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Brother or sister

Other nonrelative

Father or mother

Father or mother

3 What is Person 3’s sex? Mark (X) ONE box.
Male

3 What is Person 4’s sex? Mark (X) ONE box.

Female

Male

4 What is Person 3’s age and what is Person 3’s date of birth?

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.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Age (in years)

Age (in years)

Month

Day

Year of birth

5 Where was this person born?

Month

Day

Year of birth

5 Where was this person born?

In the United States – Print name of state.

In the United States – Print name of state.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.

6 Is this person a citizen of the United States?

6 Is this person a citizen of the United States?

Yes, born in the United States – Continue with Person 4 in the
next column if there are 4 people. Otherwise, SKIP to page 4

Yes, born in the United States – SKIP to page 4

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

Yes, born abroad of U.S. citizen parent
or parents

Yes, born abroad of U.S. citizen parent
or parents

Yes, U.S. citizen by naturalization – Print year
of naturalization

Yes, U.S. citizen by naturalization – Print year
of naturalization

No, not a U.S. citizen

No, not a U.S. citizen

7 When did this person come to live in the

7 When did this person come to live in the

United States? Print numbers in boxes.
Year

United States? Print numbers in boxes.
Year

3
ACS-1(2011)KFI, Page 3, Base (Black)

ACS-1(2011)KFI, Page 3, Green Pantone 354 (20 and 40%)

Person 1

9 What is the highest degree or level of school

11 a. Does this person speak a language other than
English at home?

this person has COMPLETED? Mark (X) ONE box.

➜

Please copy the name of Person 1 from page 2,
then continue answering questions below.

If currently enrolled, mark the previous grade or
highest degree received.

Yes

NO SCHOOLING COMPLETED

No ➔ SKIP to B

No schooling completed

b. What is this language?

NURSERY OR PRESCHOOL THROUGH GRADE 12

Last Name

Nursery school
For example: Korean, Italian, Spanish, Vietnamese

Kindergarten
First Name

Grade 1 through 11 – Specify
grade 1 – 11

MI

B

Answer question 12 if this person is 15
years old or over. Otherwise SKIP to the
questions for Person 2 on page 5.

12 a. What is this person’s current marital status?
Mark (X) ONE box.

12th grade – NO DIPLOMA

a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include

8

Now married ➔ SKIP to question 13

HIGH SCHOOL GRADUATE

only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

Widowed

Regular high school diploma

Divorced

GED or alternative credential

No, has not attended in the last 3
months ➔ SKIP to question 9

Separated

COLLEGE OR SOME COLLEGE

Yes, public school, public college

Some college credit, but less than 1 year of
college credit

Yes, private school, private college,
home school

1 or more years of college credit, no degree

Never married

b. Is this person currently living in a registered
domestic partnership or civil union?
Yes ➔ SKIP to C

Associate’s degree (for example: AA, AS)
b. What grade or level was this person attending?
Mark (X) ONE box.

c. Is this person currently living with a boyfriend/
girlfriend or partner in this household?

AFTER BACHELOR’S DEGREE

Nursery school, preschool

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)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

Doctorate degree (for example: PhD, EdD)

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)

No

Bachelor’s degree (for example: BA, BS)

Yes
No

C

Answer questions 13-15 if this person is now
married, widowed, divorced or separated.
Otherwise SKIP to D .

13 In the PAST 12 MONTHS did this person get –
Yes

A

Answer question 10 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 11.

No

a. Married?
b. Widowed?
c. Divorced?

14 How many times has this person been married?
Once

10 This question focuses on this person’s

Two times
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
Three or more times
this person has received. (For example: chemical
engineering, elementary teacher education,
15 In what year did this person last get married?
organizational psychology)
Year

D

Answer question 16 if female and 15-50
years old.

16 Has this person given birth to any children in
the past 12 months?
Yes
No

4
ACS-1(2011)KFI, Page 4, Base (Black)

ACS-1(2011)KFI, Page 4, Green Pantone 354 (20 and 40%)

Person 2

9 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜
➜

If only one person lives here, SKIP to page 8.
Please copy the name of Person 2 from page 2,
then continue answering questions below.

11 a. Does this person speak a language other than
English at home?

If currently enrolled, mark the previous grade or
highest degree received.

Yes

NO SCHOOLING COMPLETED

No ➔ SKIP to B

No schooling completed

b. What is this language?

NURSERY OR PRESCHOOL THROUGH GRADE 12

Last Name

Nursery school
For example: Korean, Italian, Spanish, Vietnamese

Kindergarten
First Name

Grade 1 through 11 – Specify
grade 1 – 11

MI

B

Answer question 12 if this person is 15
years old or over. Otherwise SKIP to the
questions for Person 3 on page 6.

12 a. What is this person’s current marital status?
8

Mark (X) ONE box.

12th grade – NO DIPLOMA

a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include

Now married ➔ SKIP to question 13

HIGH SCHOOL GRADUATE

only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

Widowed

Regular high school diploma

Divorced

GED or alternative credential

No, has not attended in the last 3
months ➔ SKIP to question 9

Separated

COLLEGE OR SOME COLLEGE

Yes, public school, public college

Some college credit, but less than 1 year of
college credit

Yes, private school, private college,
home school

1 or more years of college credit, no degree

Never married

b. Is this person currently living in a registered
domestic partnership or civil union?
Yes ➔ SKIP to C

Associate’s degree (for example: AA, AS)
b. What grade or level was this person attending?
Mark (X) ONE box.

c. Is this person currently living with a boyfriend/
girlfriend or partner in this household?

AFTER BACHELOR’S DEGREE

Nursery school, preschool

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)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

Doctorate degree (for example: PhD, EdD)

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)

No

Bachelor’s degree (for example: BA, BS)

Yes
No

C

Answer questions 13-15 if this person is now
married, widowed, divorced or separated.
Otherwise SKIP to D .

13 In the PAST 12 MONTHS did this person get –
Yes

A

Answer question 10 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 11.

No

a. Married?
b. Widowed?
c. Divorced?

14 How many times has this person been married?
Once

10 This question focuses on this person’s

Two times
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
Three or more times
this person has received. (For example: chemical
engineering, elementary teacher education,
15 In what year did this person last get married?
organizational psychology)
Year

D

Answer question 16 if female and 15-50
years old.

16 Has this person given birth to any children in
the past 12 months?
Yes
No

5
ACS-1(2011)KFI, Page 5, Base (Black)

ACS-1(2011)KFI, Page 5, Green Pantone 354 (10, 20, 40 and 50%)

Person 3

9 What is the highest degree or level of school

11 a. Does this person speak a language other than
English at home?

this person has COMPLETED? Mark (X) ONE box.

➜

If only two persons live here, SKIP to page 8.

➜

Please copy the name of Person 3 from page 3,
then continue answering questions below.

If currently enrolled, mark the previous grade or
highest degree received.

Yes

NO SCHOOLING COMPLETED

No ➔ SKIP to B

No schooling completed

b. What is this language?

NURSERY OR PRESCHOOL THROUGH GRADE 12

Last Name

Nursery school
For example: Korean, Italian, Spanish, Vietnamese

Kindergarten
First Name

Grade 1 through 11 – Specify
grade 1 – 11

MI

B

Answer question 12 if this person is 15
years old or over. Otherwise SKIP to the
questions for Person 4 on page 7.

12 a. What is this person’s current marital status?
Mark (X) ONE box.

12th grade – NO DIPLOMA

a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include

8

Now married ➔ SKIP to question 13

HIGH SCHOOL GRADUATE

only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

Widowed

Regular high school diploma

Divorced

GED or alternative credential

No, has not attended in the last 3
months ➔ SKIP to question 11

Separated

COLLEGE OR SOME COLLEGE

Yes, public school, public college

Some college credit, but less than 1 year of
college credit

Yes, private school, private college,
home school

1 or more years of college credit, no degree

Never married

b. Is this person currently living in a registered
domestic partnership or civil union?
Yes ➔ SKIP to C

Associate’s degree (for example: AA, AS)
b. What grade or level was this person attending?
Mark (X) ONE box.

c. Is this person currently living with a boyfriend/
girlfriend or partner in this household?

AFTER BACHELOR’S DEGREE

Nursery school, preschool

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)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

Doctorate degree (for example: PhD, EdD)

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)

No

Bachelor’s degree (for example: BA, BS)

Yes
No

C

Answer questions 13-15 if this person is now
married, widowed, divorced or separated.
Otherwise SKIP to D .

13 In the PAST 12 MONTHS did this person get –
Yes

A

Answer question 10 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 11.

No

a. Married?
b. Widowed?
c. Divorced?

14 How many times has this person been married?
Once

10 This question focuses on this person’s

Two times
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
Three or more times
this person has received. (For example: chemical
engineering, elementary teacher education,
15 In what year did this person last get married?
organizational psychology)
Year

D

Answer question 16 if female and 15-50
years old.

16 Has this person given birth to any children in
the past 12 months?
Yes
No

6
ACS-1(2011)KFI, Page 6, Base (Black)

ACS-1(2011)KFI, Page 6, Green Pantone 354 (10, 20, 40 and 50%)

Person 4

9 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜
➜

If only three persons live here, SKIP to page 8.
Please copy the name of Person 4 from page 3,
then continue answering questions below.

11 a. Does this person speak a language other than
English at home?

If currently enrolled, mark the previous grade or
highest degree received.

Yes

NO SCHOOLING COMPLETED

No ➔ SKIP to B

No schooling completed

b. What is this language?

NURSERY OR PRESCHOOL THROUGH GRADE 12

Last Name

Nursery school
For example: Korean, Italian, Spanish, Vietnamese

Kindergarten
First Name

Grade 1 through 11 – Specify
grade 1 – 11

MI

B

Answer question 12 if this person is 15
years old or over.

12 a. What is this person’s current marital status?
8

Mark (X) ONE box.

12th grade – NO DIPLOMA

a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include

Now married ➔ SKIP to question 13

HIGH SCHOOL GRADUATE

only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.

Widowed

Regular high school diploma

Divorced

GED or alternative credential

No, has not attended in the last 3
months ➔ SKIP to question 11

Separated

COLLEGE OR SOME COLLEGE

Yes, public school, public college

Some college credit, but less than 1 year of
college credit

Yes, private school, private college,
home school

1 or more years of college credit, no degree

Never married

b. Is this person currently living in a registered
domestic partnership or civil union?
Yes ➔ SKIP to C

Associate’s degree (for example: AA, AS)
b. What grade or level was this person attending?
Mark (X) ONE box.

c. Is this person currently living with a boyfriend/
girlfriend or partner in this household?

AFTER BACHELOR’S DEGREE

Nursery school, preschool

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)

Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

Doctorate degree (for example: PhD, EdD)

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)

No

Bachelor’s degree (for example: BA, BS)

Yes
No

C

Answer questions 13-15 if this person is now
married, widowed, divorced or separated.
Otherwise SKIP to D .

13 In the PAST 12 MONTHS did this person get –
Yes

A

Answer question 10 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 11.

No

a. Married?
b. Widowed?
c. Divorced?

14 How many times has this person been married?
Once

10 This question focuses on this person’s

Two times
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
Three or more times
this person has received. (For example: chemical
engineering, elementary teacher education,
15 In what year did this person last get married?
organizational psychology)
Year

D

Answer question 16 if female and 15-50
years old.

16 Has this person given birth to any children in
the past 12 months?
Yes
No

7
ACS-1(2011)KFI, Page 7, Base (Black)

ACS-1(2011)KFI, Page 7, Green Pantone 354 (10, 20, 40 and 50%)

Mailing
Instructions
➜ Please make sure you have...

• listed all names and answered the questions on
pages 2, and 3
• 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 CLERK

EDIT

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 0607-0725, 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
0607-0725" 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(2011)RELMAR (V4) (10-28-2010)

8
ACS-1(2010)KFI, Page 28, Base (Black)

ACS-1(2010)KFI, Page 28, Green Pantone 354 (20, 40 and 50%)