Various Demographic Pretesting Activities

13853015

DC

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

Start Here
Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it
back as soon as possible.

➜

➜

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.
If you need help or have
questions about completing
this form, please call
1-800-354-7271.
The telephone call is free.

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

Area Code + Number

—

➜

¿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
completar su entrevista por teléfono con
un entrevistador que habla español.
O puede responder por Internet en:
https://respond.census.gov/acs

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.

ACS-1(X)QD85

FORM
(07-19-2012) Draft 10

§.v?0¤

MI

First Name

Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call
is free.

For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

Please print today’s date.

OMB No. 0607-0936
Approval Expires 12/31/2012

13853023

Person 1

Person 2
1

(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.)

What is Person 2’s name?
First Name

Last Name (Please print)

2

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

1

Biological son or daughter

What is Person 1’s name?
Last Name (Please print)

First Name

Adopted son or daughter

MI

Stepson or stepdaughter
Brother or sister

2

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

3

Male

4

3
4

child is less than 1 year old.
Age (in years)

6

Female

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

Age (in years)

➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.

5

Housemate or roommate

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

What is Person 1’s age and what is Person 1’s
date of birth? Please report babies as age 0 when the

Roomer or boarder

Other nonrelative

Parent-in-law

Female

Other relative

Foster child

Grandchild

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

Son-in-law or
daughter-in-law

Unmarried partner

Father or mother

X Person 1

MI

Is Person 1 of Hispanic, Latino, or Spanish origin?

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?

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. C

Yes, another Hispanic, Latino, or Spanish origin –
Print origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

What is Person 1’s race? Mark (X) one or more boxes.

6

What is Person 2’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. C

American Indian or Alaska Native – Print name of
enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Chinese

Korean

Filipino

Vietnamese

Guamanian or
Chamorro

Filipino

Vietnamese

Guamanian or
Chamorro

Other Asian –
Print race, for
example, Hmong,
Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Samoan

Other Asian –
Print race, for
example, Hmong,
Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

Some other race – Print race. C

§.v?8¤

Some other race – Print race. C

2

Samoan
Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

13853031

Person 3
1

1

What is Person 3’s name?
Last Name (Please print)

2

First Name

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister

2

Son-in-law or
daughter-in-law
Other relative

Stepson or stepdaughter

Housemate or roommate

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

Adopted son or daughter

Roomer or boarder

Brother or sister

4

child is less than 1 year old.
Age (in years)

6

Housemate or roommate

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

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.
Month Day
Year of birth

Age (in years)

➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.

5

Roomer or boarder

Other nonrelative

Parent-in-law

Male

What is Person 3’s age and what is Person 3’s
date of birth? Please report babies as age 0 when the

Other relative

Foster child

Grandchild

3

Son-in-law or
daughter-in-law

Unmarried partner

Father or mother

Female

MI

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

Other nonrelative

Parent-in-law

First Name

Husband or wife

Foster child

Grandchild

What is Person 4’s name?
Last Name (Please print)

Unmarried partner

Father or mother

4

MI

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

3

Person 4

Is Person 3 of Hispanic, Latino, or Spanish origin?

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 4 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. C

Yes, another Hispanic, Latino, or Spanish origin –
Print origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

What is Person 3’s race? Mark (X) one or more boxes.

6

What is Person 4’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. C

American Indian or Alaska Native – Print name of
enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Chinese

Korean

Filipino

Vietnamese

Guamanian or
Chamorro

Filipino

Vietnamese

Guamanian or
Chamorro

Other Asian –
Print race, for
example, Hmong,
Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Samoan

Other Asian –
Print race, for
example, Hmong,
Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

Some other race – Print race. C

§.v?@¤

Some other race – Print race. C

3

Samoan
Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

13853049

Person 5
1

What is Person 5’s name?
Last Name (Please print)

2

First Name

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. C

Person 6

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister

Last Name (Please print)

MI

Other relative
Sex

Roomer or boarder

Male

Female

Age (in years)

Housemate or roommate

Person 7

Foster child

Grandchild

First Name

Son-in-law or
daughter-in-law

Unmarried partner

Father or mother

Last Name (Please print)

First Name

MI

Other nonrelative

Parent-in-law

What is Person 5’s sex? Mark (X) ONE box.
Male

4

MI

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

3

➜

Sex

Female

What is Person 5’s age and what is Person 5’s
date of birth? Please report babies as age 0 when the

Male

Female

Age (in years)

Person 8

child is less than 1 year old.
Age (in years)

Print numbers in boxes.
Month Day
Year of birth

Last Name (Please print)

➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.

5

Sex

Is Person 5 of Hispanic, Latino, or Spanish origin?

Male

First Name

Female

MI

Age (in years)

Person 9

No, not of Hispanic, Latino, or Spanish origin

Last Name (Please print)

Yes, Mexican, Mexican Am., Chicano

First Name

MI

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. C

6

Male

Female

Age (in years)

Person 10
Last Name (Please print)

What is Person 5’s race? Mark (X) one or more boxes.

First Name

MI

White
Black, African Am., or Negro
American Indian or Alaska Native – Print name of
enrolled or principal tribe. C

Sex

Male

Female

Age (in years)

Person 11
Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Filipino

Vietnamese

Guamanian or
Chamorro

Other Asian –
Print race, for
example, Hmong,
Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Last Name (Please print)

First Name

Samoan
Sex

Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

Male

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race. C
Sex

§.v?R¤

MI

4

Male

Female

Age (in years)

MI

13853056

Housing
➜

1

Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.

A

Answer questions 4 – 6 if this is a HOUSE OR A
MOBILE HOME; otherwise, SKIP to question 7a.

4

How many acres is this house or mobile home on?

A mobile home
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

Less than 1 acre ➔ SKIP to question 6
1 to 9.9 acres
10 or more acres

5

A building with 5 to 9 apartments

IN THE PAST 12 MONTHS, what were the actual
sales of all agricultural products from this
property?

A building with 10 to 19 apartments
A building with 20 to 49 apartments

None

A building with 50 or more apartments

$1 to $999

Boat, RV, van, etc.

$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999

2

About when was this building first built?

$10,000 or more

2000 or later – Specify year

6
1990 to 1999

Is there a business (such as a store or barber shop)
or a medical office on this property?
Yes

1980 to 1989

No

1970 to 1979
1960 to 1969
1950 to 1959

7

1940 to 1949
1939 or earlier

3

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.

When did PERSON 1 (listed on page 2) move into
this house, apartment, or mobile home?

Number of rooms

Month 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".
Number of bedrooms

§.v?Y¤

5

13853064

Housing (continued)
8

Does this house, apartment, or mobile home
have –
Yes
No

12 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?

a. hot and cold running water?

None

b. a flush toilet?

1

c. a bathtub or shower?

2

d. a sink with a faucet?

3
4

e. a stove or range?

5

f. a refrigerator?
g. telephone service from which
you can both make and receive
calls? Include cell phones.

6 or more

13 Which FUEL is used MOST for heating this
house, apartment, or mobile home?

9

At this house, apartment, or mobile home –
do you or any member of this household
own or use any of the following computers?
• EXCLUDE GPS devices, digital music players, and
devices with only limited computing capabilities,
for example: household appliances.
Yes
No
a. Desktop, laptop, netbook, or
notebook computer

Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood

b. Handheld computer,
smart mobile phone, or other
handheld wireless computer

Solar energy
Other fuel

c. Some other type of computer
Specify C

No fuel used

14 a. LAST MONTH, what was the cost of electricity
for this house, apartment, or mobile home?
Last month’s cost – Dollars

10 At this house, apartment, or mobile home –
do you or any member of this household access
the Internet?

$

.00

,

Yes, with a subscription to an Internet service

OR

Yes, without a subscription to an Internet
service ➔ SKIP to question 12

Included in rent or condominium fee
No charge or electricity not used

No Internet access at this house, apartment,
or mobile home ➔ SKIP to question 12

b. LAST MONTH, what was the cost of gas for this
house, apartment, or mobile home?

11 At this house, apartment, or mobile home –

Last month’s cost – Dollars

do you or any member of this household
subscribe to the Internet using –
Yes
No

$

a. Dial-up service?

.00

,
OR

b. DSL service?

Included in rent or condominium fee

c. Cable modem service?

Included in electricity payment entered above
No charge or gas not used

d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite Internet service?
g. Some other service?
Specify service C

§.v?a¤

6

13853072

Housing (continued)
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.

17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this household
with a mortgage or loan? Include home
equity loans.

Past 12 months’ cost – Dollars
$

Owned by you or someone in this household
free and clear (without a mortgage or loan)?

.00

,
OR

Rented?
Occupied without payment of rent? ➔ SKIP to C

Included in rent or condominium fee
No charge
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.
Past 12 months’ cost – Dollars
$

B

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

18 a. What is the monthly rent for this
house, apartment, or mobile home?

.00

,

Monthly amount – Dollars

OR

$

No charge or these fuels not used

b. Does the monthly rent include any meals?
Yes

15 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits from
the Food Stamp Program or SNAP (the
Supplemental Nutrition Assistance Program)?
Do NOT include WIC, the School Lunch Program, or
assistance from food banks.

.00

,

Included in rent or condominium fee

No

C

Yes

Answer questions 19 – 23 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E on the next page.

No

16 Is this house, apartment, or mobile home part of

19 About how much do you think this house and lot,
apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?

a condominium?

Amount – Dollars
Yes ➔ What is the monthly condominium fee?
For renters, answer only if you pay the
$
.00
condominium fee in addition to your rent;
,
,
otherwise, mark the "None" box.
Monthly amount – Dollars
20 What are the annual real estate taxes on THIS
property?
$
.00
Annual amount – Dollars
,
OR

$

.00

,

None

OR
No

None

21 What is the annual payment for fire, hazard, and
flood insurance on THIS property?
Annual amount – Dollars
$

.00

,
OR
None

§.v?i¤

7

13853080

Housing (continued)
22 a. Do you or any member of this household have
a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?

D

Answer question 24 if this is a MOBILE HOME.
Otherwise, SKIP to E .

Yes, mortgage, deed of trust, or similar debt
Yes, contract to purchase
No ➔ SKIP to question 23a

24 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.

b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.

Annual costs – Dollars

Monthly amount – Dollars
$

,

$

.00

,

.00

OR
No regular payment required ➔ SKIP to
question 23a

E

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
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

23 a. Do you or any member of this household have
a second mortgage or a home equity loan on
THIS property?
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home equity loan
No ➔ SKIP to D
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
$

,

.00

OR
No regular payment required

§.v?q¤

8

Answer questions about PERSON 1 on the next
page if you listed at least one person on page 2.
Otherwise, SKIP to page 44 for the mailing
instructions.

13853098

Person 1
➜

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

First Name

10 a. At any time IN THE LAST 3 MONTHS, has this
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 13
Yes, public school, public college

MI

Yes, private school, private college,
home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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

8

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)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents

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.

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

No, not a U.S. citizen

Nursery school
Kindergarten

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.v?¥¤

9

13853106

Person 1 (continued)
F

Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.

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

12 This question focuses on this person’s

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

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)

No, different house in the United States
or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?

Name of city, town, or post office
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

Name of U.S. county or
municipio in Puerto Rico

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

Name of U.S. state or
Puerto Rico

No ➔ SKIP to question 15a

ZIP Code

b. What is this language?

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

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all

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

§.v@’¤

10

13853114

Person 1 (continued)
17 a. Is this person deaf or does he/she have
serious difficulty hearing?

H

Yes

Answer question 19 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 16.

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

19 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

Yes

Yes

No

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 16.

20 What is this person’s marital status?
Now married
Widowed
Divorced

18 a. Because of a physical, mental, or emotional

Separated

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

Never married ➔ SKIP to

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

b. Does this person have serious difficulty
walking or climbing stairs?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No
c. Does this person have difficulty dressing or
bathing?

I on the next page

22 How many times has this person been married?

Yes

Once

No

Two times
Three or more times

23 In what year did this person last get married?
Year

§.v@/¤

11

13853122

Person 1 (continued)
I

Answer question 24 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 25a.

26 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

24 Has this person given birth to any children in the
past 12 months?

Now on active duty
On active duty in the past, but not now

Yes
No

27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

September 2001 or later

No ➔ SKIP to question 26

August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 26

January 1947 to June 1950

World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
November 1941 or earlier
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
28 a. Does this person have a VA service-connected
the grandparent has been responsible for the
disability rating?
longest period of time.
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 29a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years
5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.v@7¤

12

13853130

Person 1 (continued)
29 a. LAST WEEK, did this person work for pay at a
job (or business)?

J

Yes ➔ SKIP to question 30

Answer question 32 if you marked "Car, truck,
or van" in question 31. Otherwise, SKIP to
question 33.

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?

32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

Yes
No ➔ SKIP to question 35a

30 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

33 What time did this person usually leave home to
go to work LAST WEEK?
Hour

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.

p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

a.m.

Minutes

K

Yes

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise, SKIP to
question 39a.

No, outside the city/town limits
d. Name of county

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. Name of U.S. state or foreign country

No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal reasons,
bad weather, etc. ➔ SKIP to question 38
No ➔ SKIP to question 36

31 How did this person usually get to work LAST

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?

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.
Motorcycle

Yes ➔ SKIP to question 37

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Car, truck, or van

Taxicab

§.v@?¤

13

13853148

Person 1 (continued)
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

L

Answer questions 41 – 46 if this person worked in
the past 5 years. Otherwise, SKIP to question 47.

Yes
No ➔ SKIP to question 38
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.

37 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

41 Was this person –
Mark (X) ONE box.

38 When did this person last work, even for a
few days?

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Within the past 12 months
1 to 5 years ago ➔ SKIP to L

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

Over 5 years ago or never worked ➔ SKIP to
question 47

a local GOVERNMENT employee
(city, county, etc.)?

39 a. During the PAST 12 MONTHS (52 weeks), did

a state GOVERNMENT employee?

this person work 50 or more weeks? Count
paid time off as work.

a Federal GOVERNMENT employee?

Yes ➔ SKIP to question 40

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

working WITHOUT PAY in family business
or farm?

50 to 52 weeks
48 to 49 weeks

42 For whom did this person work?

40 to 47 weeks

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

27 to 39 weeks
14 to 26 weeks

Name of company, business, or other employer

13 weeks or less

40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Usual hours worked each WEEK

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.v@Q¤

14

13853155

Person 1 (continued)
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

or duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

TOTAL AMOUNT for past
12 months

Yes ➔
No

No

TOTAL AMOUNT for past
12 months

Yes ➔
.00

No

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

48 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 47a 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.

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
$

.00

,

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.

TOTAL AMOUNT for past
12 months

$

No

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.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

,

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.)

,

$

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

$

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important activities

Yes ➔

$

OR

.00
None

Loss

TOTAL AMOUNT for past
12 months

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
No

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

§.v@X¤

15

Continue with the questions for Person 2 on the
next page. If no one is listed as Person 2 on page 2,
SKIP to page 44 for mailing instructions.

13853163

Person 2
➜

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

First Name

10 a. At any time IN THE LAST 3 MONTHS, has this
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 13
Yes, public school, public college

MI

Yes, private school, private college,
home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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

8

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)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents

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.

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

No, not a U.S. citizen

Nursery school
Kindergarten

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.v@‘¤

16

13853171

Person 2 (continued)
F

Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.

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

12 This question focuses on this person’s

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

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)

No, different house in the United States
or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?

Name of city, town, or post office
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

Name of U.S. county or
municipio in Puerto Rico

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

Name of U.S. state or
Puerto Rico

No ➔ SKIP to question 15a

ZIP Code

b. What is this language?

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

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all

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

§.v@h¤

17

13853189

Person 2 (continued)
17 a. Is this person deaf or does he/she have
serious difficulty hearing?

H

Yes

Answer question 19 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 23.

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

19 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

Yes

Yes

No

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 23.

20 What is this person’s marital status?
Now married
Widowed
Divorced

18 a. Because of a physical, mental, or emotional

Separated

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

Never married ➔ SKIP to

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

b. Does this person have serious difficulty
walking or climbing stairs?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No
c. Does this person have difficulty dressing or
bathing?

I on the next page

22 How many times has this person been married?

Yes

Once

No

Two times
Three or more times

23 In what year did this person last get married?
Year

§.v@z¤

18

13853197

Person 2 (continued)
I

Answer question 24 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 25a.

26 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

24 Has this person given birth to any children in the
past 12 months?

Now on active duty
On active duty in the past, but not now

Yes
No

27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

September 2001 or later

No ➔ SKIP to question 26

August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 26

January 1947 to June 1950

World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
November 1941 or earlier
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
28 a. Does this person have a VA service-connected
the grandparent has been responsible for the
disability rating?
longest period of time.
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 29a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years
5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.v@¿¤

19

13853205

Person 2 (continued)
29 a. LAST WEEK, did this person work for pay at a
job (or business)?

J

Yes ➔ SKIP to question 30

Answer question 32 if you marked "Car, truck,
or van" in question 31. Otherwise, SKIP to
question 33.

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?

32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

Yes
No ➔ SKIP to question 35a

30 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

33 What time did this person usually leave home to
go to work LAST WEEK?
Hour

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.

p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

a.m.

Minutes

K

Yes

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise, SKIP to
question 39a.

No, outside the city/town limits
d. Name of county

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. Name of U.S. state or foreign country

No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal reasons,
bad weather, etc. ➔ SKIP to question 38
No ➔ SKIP to question 36

31 How did this person usually get to work LAST

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?

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.
Motorcycle

Yes ➔ SKIP to question 37

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Car, truck, or van

Taxicab

§.vA&¤

20

13853213

Person 2 (continued)
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

L

Answer questions 41 – 46 if this person worked in
the past 5 years. Otherwise, SKIP to question 47.

Yes
No ➔ SKIP to question 38
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.

37 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

41 Was this person –
Mark (X) ONE box.

38 When did this person last work, even for a
few days?

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Within the past 12 months
1 to 5 years ago ➔ SKIP to L

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

Over 5 years ago or never worked ➔ SKIP to
question 47

a local GOVERNMENT employee
(city, county, etc.)?

39 a. During the PAST 12 MONTHS (52 weeks), did

a state GOVERNMENT employee?

this person work 50 or more weeks? Count
paid time off as work.

a Federal GOVERNMENT employee?

Yes ➔ SKIP to question 40

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

working WITHOUT PAY in family business
or farm?

50 to 52 weeks
48 to 49 weeks

42 For whom did this person work?

40 to 47 weeks

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

27 to 39 weeks
14 to 26 weeks

Name of company, business, or other employer

13 weeks or less

40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Usual hours worked each WEEK

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.vA.¤

21

13853221

Person 2 (continued)
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

or duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

TOTAL AMOUNT for past
12 months

Yes ➔
No

No

TOTAL AMOUNT for past
12 months

Yes ➔
.00

No

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

48 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 47a 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.

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
$

.00

,

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.

TOTAL AMOUNT for past
12 months

$

No

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.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

,

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.)

,

$

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

$

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important activities

Yes ➔

$

OR

.00
None

Loss

TOTAL AMOUNT for past
12 months

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
No

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

§.vA6¤

22

Continue with the questions for Person 3 on the
next page. If no one is listed as Person 3 on page 3,
SKIP to page 44 for mailing instructions.

13853239

Person 3
➜

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

First Name

10 a. At any time IN THE LAST 3 MONTHS, has this
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 13
Yes, public school, public college

MI

Yes, private school, private college,
home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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

8

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)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents

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.

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

No, not a U.S. citizen

Nursery school
Kindergarten

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.vAH¤

23

13853247

Person 3 (continued)
F

Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.

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

12 This question focuses on this person’s

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

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)

No, different house in the United States
or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?

Name of city, town, or post office
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

Name of U.S. county or
municipio in Puerto Rico

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

Name of U.S. state or
Puerto Rico

No ➔ SKIP to question 15a

ZIP Code

b. What is this language?

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

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all

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

§.vAP¤

24

13853254

Person 3 (continued)
17 a. Is this person deaf or does he/she have
serious difficulty hearing?

H

Yes

Answer question 19 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 30.

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

19 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

Yes

Yes

No

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 30.

20 What is this person’s marital status?
Now married
Widowed
Divorced

18 a. Because of a physical, mental, or emotional

Separated

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

Never married ➔ SKIP to

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

b. Does this person have serious difficulty
walking or climbing stairs?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No
c. Does this person have difficulty dressing or
bathing?

I on the next page

22 How many times has this person been married?

Yes

Once

No

Two times
Three or more times

23 In what year did this person last get married?
Year

§.vAW¤

25

13853262

Person 3 (continued)
I

Answer question 24 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 25a.

26 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

24 Has this person given birth to any children in the
past 12 months?

Now on active duty
On active duty in the past, but not now

Yes
No

27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

September 2001 or later

No ➔ SKIP to question 26

August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 26

January 1947 to June 1950

World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
November 1941 or earlier
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
28 a. Does this person have a VA service-connected
the grandparent has been responsible for the
disability rating?
longest period of time.
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 29a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years
5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.vA_¤

26

13853270

Person 3 (continued)
29 a. LAST WEEK, did this person work for pay at a
job (or business)?

J

Yes ➔ SKIP to question 30

Answer question 32 if you marked "Car, truck,
or van" in question 31. Otherwise, SKIP to
question 33.

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?

32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

Yes
No ➔ SKIP to question 35a

30 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

33 What time did this person usually leave home to
go to work LAST WEEK?
Hour

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.

p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

a.m.

Minutes

K

Yes

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise, SKIP to
question 39a.

No, outside the city/town limits
d. Name of county

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. Name of U.S. state or foreign country

No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal reasons,
bad weather, etc. ➔ SKIP to question 38
No ➔ SKIP to question 36

31 How did this person usually get to work LAST

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?

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.
Motorcycle

Yes ➔ SKIP to question 37

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Car, truck, or van

Taxicab

§.vAg¤

27

13853288

Person 3 (continued)
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

L

Answer questions 41 – 46 if this person worked in
the past 5 years. Otherwise, SKIP to question 47.

Yes
No ➔ SKIP to question 38
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.

37 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

41 Was this person –
Mark (X) ONE box.

38 When did this person last work, even for a
few days?

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Within the past 12 months
1 to 5 years ago ➔ SKIP to L

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

Over 5 years ago or never worked ➔ SKIP to
question 47

a local GOVERNMENT employee
(city, county, etc.)?

39 a. During the PAST 12 MONTHS (52 weeks), did

a state GOVERNMENT employee?

this person work 50 or more weeks? Count
paid time off as work.

a Federal GOVERNMENT employee?

Yes ➔ SKIP to question 40

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

working WITHOUT PAY in family business
or farm?

50 to 52 weeks
48 to 49 weeks

42 For whom did this person work?

40 to 47 weeks

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

27 to 39 weeks
14 to 26 weeks

Name of company, business, or other employer

13 weeks or less

40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Usual hours worked each WEEK

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.vAy¤

28

13853296

Person 3 (continued)
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

or duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

TOTAL AMOUNT for past
12 months

Yes ➔
No

No

TOTAL AMOUNT for past
12 months

Yes ➔
.00

No

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

48 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 47a 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.

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
$

.00

,

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.

TOTAL AMOUNT for past
12 months

$

No

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.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

,

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.)

,

$

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

$

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important activities

Yes ➔

$

OR

.00
None

Loss

TOTAL AMOUNT for past
12 months

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
No

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

§.vA£¤

29

Continue with the questions for Person 4 on the
next page. If no one is listed as Person 4 on page 3,
SKIP to page 44 for mailing instructions.

13853304

Person 4
➜

Please copy the name of Person 4 from page 3,
then continue answering questions below.
Last Name

First Name

10 a. At any time IN THE LAST 3 MONTHS, has this
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 13
Yes, public school, public college

MI

Yes, private school, private college,
home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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

8

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)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents

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.

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

No, not a U.S. citizen

Nursery school
Kindergarten

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.vB%¤

30

13853312

Person 4 (continued)
F

Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.

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

12 This question focuses on this person’s

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

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)

No, different house in the United States
or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?

Name of city, town, or post office
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

Name of U.S. county or
municipio in Puerto Rico

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

Name of U.S. state or
Puerto Rico

No ➔ SKIP to question 15a

ZIP Code

b. What is this language?

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

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all

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

§.vB-¤

31

13853320

Person 4 (continued)
17 a. Is this person deaf or does he/she have
serious difficulty hearing?

H

Yes

Answer question 19 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 37.

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

19 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

Yes

Yes

No

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 37.

20 What is this person’s marital status?
Now married
Widowed
Divorced

18 a. Because of a physical, mental, or emotional

Separated

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

Never married ➔ SKIP to

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

b. Does this person have serious difficulty
walking or climbing stairs?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No
c. Does this person have difficulty dressing or
bathing?

I on the next page

22 How many times has this person been married?

Yes

Once

No

Two times
Three or more times

23 In what year did this person last get married?
Year

§.vB5¤

32

13853338

Person 4 (continued)
I

Answer question 24 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 25a.

26 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

24 Has this person given birth to any children in the
past 12 months?

Now on active duty
On active duty in the past, but not now

Yes
No

27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

September 2001 or later

No ➔ SKIP to question 26

August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 26

January 1947 to June 1950

World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
November 1941 or earlier
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
28 a. Does this person have a VA service-connected
the grandparent has been responsible for the
disability rating?
longest period of time.
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 29a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years
5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.vBG¤

33

13853346

Person 4 (continued)
29 a. LAST WEEK, did this person work for pay at a
job (or business)?

J

Yes ➔ SKIP to question 30

Answer question 32 if you marked "Car, truck,
or van" in question 31. Otherwise, SKIP to
question 33.

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?

32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

Yes
No ➔ SKIP to question 35a

30 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

33 What time did this person usually leave home to
go to work LAST WEEK?
Hour

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.

p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

a.m.

Minutes

K

Yes

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise, SKIP to
question 39a.

No, outside the city/town limits
d. Name of county

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. Name of U.S. state or foreign country

No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal reasons,
bad weather, etc. ➔ SKIP to question 38
No ➔ SKIP to question 36

31 How did this person usually get to work LAST

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?

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.
Motorcycle

Yes ➔ SKIP to question 37

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Car, truck, or van

Taxicab

§.vBO¤

34

13853353

Person 4 (continued)
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

L

Answer questions 41 – 46 if this person worked in
the past 5 years. Otherwise, SKIP to question 47.

Yes
No ➔ SKIP to question 38
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.

37 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

41 Was this person –
Mark (X) ONE box.

38 When did this person last work, even for a
few days?

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Within the past 12 months
1 to 5 years ago ➔ SKIP to L

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

Over 5 years ago or never worked ➔ SKIP to
question 47

a local GOVERNMENT employee
(city, county, etc.)?

39 a. During the PAST 12 MONTHS (52 weeks), did

a state GOVERNMENT employee?

this person work 50 or more weeks? Count
paid time off as work.

a Federal GOVERNMENT employee?

Yes ➔ SKIP to question 40

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

working WITHOUT PAY in family business
or farm?

50 to 52 weeks
48 to 49 weeks

42 For whom did this person work?

40 to 47 weeks

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

27 to 39 weeks
14 to 26 weeks

Name of company, business, or other employer

13 weeks or less

40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Usual hours worked each WEEK

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.vBV¤

35

13853361

Person 4 (continued)
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

or duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

TOTAL AMOUNT for past
12 months

Yes ➔
No

No

TOTAL AMOUNT for past
12 months

Yes ➔
.00

No

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

48 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 47a 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.

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
$

.00

,

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.

TOTAL AMOUNT for past
12 months

$

No

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.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

,

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.)

,

$

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

$

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important activities

Yes ➔

$

OR

.00
None

Loss

TOTAL AMOUNT for past
12 months

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
No

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

§.vB^¤

36

Continue with the questions for Person 5 on the
next page. If no one is listed as Person 5 on page 4,
SKIP to page 44 for mailing instructions.

13853379

Person 5
➜

Please copy the name of Person 5 from page 4,
then continue answering questions below.
Last Name

First Name

10 a. At any time IN THE LAST 3 MONTHS, has this
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 13
Yes, public school, public college

MI

Yes, private school, private college,
home school

7

b. What grade or level was this person attending?
Mark (X) ONE box.

Where was this person born?
In the United States – Print name of state.

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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

8

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)

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
Yes, born in Puerto Rico, Guam, the U.S. Virgin
Islands, or Northern Marianas
Yes, born abroad of U.S. citizen parent or parents

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.

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

No, not a U.S. citizen

Nursery school
Kindergarten

9

Grade 1 through 11 – Specify
grade 1 – 11

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

§.vBp¤

37

13853387

Person 5 (continued)
F

Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.

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

12 This question focuses on this person’s

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

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)

No, different house in the United States
or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)

13 What is this person’s ancestry or ethnic origin?

Name of city, town, or post office
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

Name of U.S. county or
municipio in Puerto Rico

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

Name of U.S. state or
Puerto Rico

No ➔ SKIP to question 15a

ZIP Code

b. What is this language?

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

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well
Well
Not well
Not at all

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

§.vBx¤

38

13853395

Person 5 (continued)
17 a. Is this person deaf or does he/she have
serious difficulty hearing?

H

Yes

Answer question 19 if this person is 15 years old
or over. Otherwise, Otherwise, SKIP to the mailing
instructions on page 44.

No
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

19 Because of a physical, mental, or emotional
condition, does this person have difficulty doing
errands alone such as visiting a doctor’s office
or shopping?

Yes

Yes

No

No

G

Answer question 18a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 44.

20 What is this person’s marital status?
Now married
Widowed
Divorced

18 a. Because of a physical, mental, or emotional

Separated

condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

Never married ➔ SKIP to

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

b. Does this person have serious difficulty
walking or climbing stairs?

No

a. Married?
b. Widowed?

Yes

c. Divorced?

No
c. Does this person have difficulty dressing or
bathing?

I on the next page

22 How many times has this person been married?

Yes

Once

No

Two times
Three or more times

23 In what year did this person last get married?
Year

§.vB¢¤

39

13853403

Person 5 (continued)
I

Answer question 24 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 25a.

26 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to question 29a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

24 Has this person given birth to any children in the
past 12 months?

Now on active duty
On active duty in the past, but not now

Yes
No

27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

September 2001 or later

No ➔ SKIP to question 26

August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

Yes

Korean War (July 1950 to January 1955)

No ➔ SKIP to question 26

January 1947 to June 1950

World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
November 1941 or earlier
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
28 a. Does this person have a VA service-connected
the grandparent has been responsible for the
disability rating?
longest period of time.
Less than 6 months

Yes (such as 0%, 10%, 20%, ... , 100%)

6 to 11 months

No ➔ SKIP to question 29a

1 or 2 years

b. What is this person’s service-connected
disability rating?

3 or 4 years
5 or more years

0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

§.vC$¤

40

13853411

Person 5 (continued)
29 a. LAST WEEK, did this person work for pay at a
job (or business)?

J

Yes ➔ SKIP to question 30

Answer question 32 if you marked "Car, truck,
or van" in question 31. Otherwise, SKIP to
question 33.

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?

32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
Person(s)

Yes
No ➔ SKIP to question 35a

30 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.

33 What time did this person usually leave home to
go to work LAST WEEK?
Hour

a. Address (Number and street name)

Minute

:
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.

p.m.

34 How many minutes did it usually take this
person to get from home to work LAST WEEK?

b. Name of city, town, or post office

c. Is the work location inside the limits of that
city or town?

a.m.

Minutes

K

Yes

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise, SKIP to
question 39a.

No, outside the city/town limits
d. Name of county

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. Name of U.S. state or foreign country

No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal reasons,
bad weather, etc. ➔ SKIP to question 38
No ➔ SKIP to question 36

31 How did this person usually get to work LAST

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?

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.
Motorcycle

Yes ➔ SKIP to question 37

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39a

Ferryboat

Other method

Car, truck, or van

Taxicab

§.vC,¤

41

13853429

Person 5 (continued)
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

L

Answer questions 41 – 46 if this person worked in
the past 5 years. Otherwise, SKIP to question 47.

Yes
No ➔ SKIP to question 38
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.

37 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

41 Was this person –
Mark (X) ONE box.

38 When did this person last work, even for a
few days?

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Within the past 12 months
1 to 5 years ago ➔ SKIP to L

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

Over 5 years ago or never worked ➔ SKIP to
question 47

a local GOVERNMENT employee
(city, county, etc.)?

39 a. During the PAST 12 MONTHS (52 weeks), did

a state GOVERNMENT employee?

this person work 50 or more weeks? Count
paid time off as work.

a Federal GOVERNMENT employee?

Yes ➔ SKIP to question 40

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

working WITHOUT PAY in family business
or farm?

50 to 52 weeks
48 to 49 weeks

42 For whom did this person work?

40 to 47 weeks

If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

27 to 39 weeks
14 to 26 weeks

Name of company, business, or other employer

13 weeks or less

40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

43 What kind of business or industry was this?
Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Usual hours worked each WEEK

44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.vC>¤

42

13853437

Person 5 (continued)
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

or duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

TOTAL AMOUNT for past
12 months

Yes ➔
No

No

TOTAL AMOUNT for past
12 months

Yes ➔
.00

No

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

48 What was this person’s total income during the
PAST 12 MONTHS? Add entries in questions 47a 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.

b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
$

.00

,

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.

TOTAL AMOUNT for past
12 months

$

No

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.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

If net income was a loss, mark the "Loss" box to the
right of the dollar amount.

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

Mark (X) the "No" box to show types of income
NOT received.

,

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.)

,

$

f. Any public assistance or welfare payments
from the state or local welfare office.

47 INCOME IN THE PAST 12 MONTHS

$

.00

,

e. Supplemental Security Income (SSI).

46 What were this person’s most important activities

Yes ➔

$

OR

.00
None

Loss

TOTAL AMOUNT for past
12 months

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
Yes ➔
No

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

➜

§.vCF¤

43

Now continue with the mailing instructions on
page 44.

13853445

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 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 0607-0810, 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(X)QD85 (07-19-2012)

§.vCN¤

44