Various Demographic Pretesting Activities

13122015

Enclosure 6

DC

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

THE

American Community Survey

Please complete this form and return
it as soon as possible after receiving
it in the mail.
This form asks for information about
the people who are living or staying at
the address on the mailing label and
about the house, apartment, or mobile
home located at the address on the
mailing label.

Start Here
➜

➜

Please print today’s date.
Year
Month Day

Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name

First Name

MI

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

—

➜

How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people

➜

Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.

Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede pedir un cuestionario en
español o completar su entrevista por teléfono
con un entrevistador que habla español.
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

ACS-1(X)HE12

FORM
(08-13-2012) Draft 2

§.-50¤
ACS-1 KFI, Base (Black)

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

OMB No. 0607-0810

13122023

Person 1

Person 2
1 What is Person 2’s name?

(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)

Last Name (Please print)

First Name

MI

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

1

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

2

First Name

MI

How is this person related to Person 1?
X

3

Person 1

4

Female

Month

Day

Year of birth

Question 6 about race. For this survey, Hispanic origins are not races.

6

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

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Female

4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

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.

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

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.

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

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

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

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

Some other race – Print race.

2

Adopted son or daughter

Male

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5

Other relative

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

What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Son-in-law or daughter-in-law

Biological son or daughter

Parent-in-law

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

Husband or wife

§.-58¤

Some other race – Print race.

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

13122031

Person 3
1

1 What is Person 4’s name?

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

2

Person 4

First Name

MI

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

Husband or wife

Son-in-law or daughter-in-law

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Brother or sister

Unmarried partner

Father or mother

Foster child

Father or mother

Foster child

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Parent-in-law

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

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

Male

Female

What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Day

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.

6

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

Son-in-law or daughter-in-law

Age (in years)

5

MI

Biological son or daughter

Male

4

First Name

Husband or wife

Parent-in-law

3

Last Name (Please print)

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

Female

4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

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.

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

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.

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

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

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

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

Some other race – Print race.

§.-5@¤

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

Some other race – Print race.

3

13122049

➜

Person 5
1

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

First Name

MI

If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.

Person 6
Last Name (Please print)

2

First Name

MI

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

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Sex

Male

Female

Age (in years)

Person 7
Last Name (Please print)

First Name

MI

Parent-in-law

3

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

4

Sex

Female

Month

Day

Age (in years)

Last Name (Please print)

First Name

MI

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

Female

Person 8

What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Male

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

Sex

Male

Female

Age (in years)

Person 9
Last Name (Please print)

First Name

MI

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Sex

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

Male

Female

Person 10
Last Name (Please print)

6

Age (in years)

First Name

MI

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

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

Male

Female

Person 11
Last Name (Please print)

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

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

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

Age (in years)

Sex

Male

First Name

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race.
Sex

4

§.-5R¤

MI

Male

Female

Age (in years)

MI

13122056

Person 1

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

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

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

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

b. What is this language?

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

COLLEGE OR SOME COLLEGE

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

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

Very well

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

1 or more years of college credit, no degree

Not well

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

Associate’s degree (for example: AA, AS)

Not at all

AFTER BACHELOR’S DEGREE

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

No, not a U.S. citizen

Doctorate degree (for example: PhD, EdD)

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

F
10 a. At any time IN THE LAST 3 MONTHS, has this

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

person attended school or college? Include

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

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

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Kindergarten

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?

Yes, public school, public college

Nursery school, preschool

Well

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

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

9

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

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA

8

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

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Address (Number and street name)

Name of city, town, or post office

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

Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico

ZIP Code

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

§.-5Y¤

5

13122064

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 9.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
of coverage in items a – h.
19 Because of a physical, mental, or emotional
Yes No
condition, does this person have difficulty
a. Insurance through a current or
doing errands alone such as visiting a doctor’s
former employer or union (of this
office or shopping?
person or another family member)
b. Insurance purchased directly from
Yes
an insurance company (by this
No
person or another family member)
c. Medicare, for people 65 and older,
or people with certain disabilities

Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

20 What is this person’s marital status?
26 Has this person ever served on active duty in the

Now married

e. TRICARE or other military health care

Separated

Never served in the military ➔ SKIP to
question 29a

f. VA (including those who have ever
used or enrolled for VA health care)

Never married ➔ SKIP to I

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Widowed
Divorced

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

h. Any other type of health insurance
or health coverage plan – Specify

No

c. Divorced?

22 How many times has this person been married?
Answer question 17 if this person is
covered by health insurance. Otherwise,
SKIP to question 18.

17 Is the cost of the health insurance premium

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

a. Married?
b. Widowed?

Once
Two times
Three or more times

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

reduced based on this person’s family income?

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.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)

Yes

January 1947 to June 1950

No

World War II (December 1941 to December 1946)

18 a. Is this person deaf or does he/she have
serious difficulty hearing?

I

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

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

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

28 a. Does this person have a VA service-connected
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 29a

Yes
No

25 a. Does this person have any of his/her own

grandchildren under the age of 18 living in
this house or apartment?

b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent

Yes

30 or 40 percent

No ➔ SKIP to question 26

50 or 60 percent

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?
Yes
No ➔ SKIP to question 26

§.-5a¤

November 1941 or earlier

disability rating?

Yes

6

If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

g. Indian Health Service

G

c. How long has this grandparent been
responsible for these grandchildren?

70 percent or higher

13122072

Person 1 (continued)
29 a. LAST WEEK, did this person work for pay

K

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

at a job (or business)?
Yes ➔ SKIP to question 39a
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No

Yes ➔ SKIP to question 39a
No ➔ SKIP to question 35a

36 During the LAST 4 WEEKS, has this person been

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
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?
Yes ➔ SKIP to question 37
No

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.)

38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
question 47

39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 40
No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

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

§.-5i¤

7

13122080

Person 1 (continued)
L

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

41 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.

41 Was this person –

47 INCOME IN THE PAST 12 MONTHS

d. Social Security or Railroad Retirement.

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.)

Yes ➔
No

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

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

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

Yes ➔
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.

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a Federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

Yes ➔
No

No

,

,

.00

TOTAL AMOUNT for past
12 months

No

,

,

Yes ➔

No

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

$

,

.00

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

Loss

Yes ➔
No

,

$

.00

TOTAL AMOUNT for past
12 months

,

.00

,

TOTAL AMOUNT for past
12 months

No

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔ $

$

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

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

TOTAL AMOUNT for past
12 months

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

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔ $

.00

,

e. Supplemental Security Income (SSI).

Mark (X) ONE box.
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

$

.00

$

,

.00

TOTAL AMOUNT for past
12 months

Loss

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.
OR $
None

➜

8

§.-5q¤

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

Continue with the questions for Person 2 on
the next page. If no one is listed as person 2 on
page 2, STOP HERE.

13122098

Person 2

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

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

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

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

b. What is this language?

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

COLLEGE OR SOME COLLEGE

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

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

Very well

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

1 or more years of college credit, no degree

Not well

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

Associate’s degree (for example: AA, AS)

Not at all

AFTER BACHELOR’S DEGREE

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

No, not a U.S. citizen

Doctorate degree (for example: PhD, EdD)

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

F
10 a. At any time IN THE LAST 3 MONTHS, has this

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

person attended school or college? Include

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

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

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Kindergarten

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?

Yes, public school, public college

Nursery school, preschool

Well

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

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

9

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

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA

8

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

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Address (Number and street name)

Name of city, town, or post office

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

Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico

ZIP Code

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

§.-5¥¤

9

13122106

Person 2 (continued)
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
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

G

Answer question 17 if this person is
covered by health insurance.

17 Is the cost of the health insurance premium
reduced based on this person’s family income?
Yes
No

➜

Continue with the questions for Person 3 on
the next page. If no one is listed as person 3 on
page 3, STOP HERE.

10

§.-6’¤

13122114

Person 3

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

7

Grade 1 through 11 – Specify
grade 1 – 11

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

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

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

b. What is this language?

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

COLLEGE OR SOME COLLEGE

For example: Korean, Italian, Spanish, Vietnamese

c. How well does this person speak English?

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

Very well

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

1 or more years of college credit, no degree

Not well

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

Associate’s degree (for example: AA, AS)

Not at all

AFTER BACHELOR’S DEGREE

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

No, not a U.S. citizen

Doctorate degree (for example: PhD, EdD)

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

F
10 a. At any time IN THE LAST 3 MONTHS, has this

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

person attended school or college? Include

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

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

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Kindergarten

15 a. Did this person live in this house or apartment
1 year ago?

Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to question 16

No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?

Yes, public school, public college

Nursery school, preschool

Well

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

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

9

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

No ➔ SKIP to question 15a
12th grade – NO DIPLOMA

8

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

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Address (Number and street name)

Name of city, town, or post office

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

Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico

ZIP Code

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)

§.-6/¤

11

13122122

Person 3 (continued)
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
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

G

Answer question 17 if this person is
covered by health insurance.

17 Is the cost of the health insurance premium
reduced based on this person’s family income?
Yes
No

➜

STOP HERE

12

§.-67¤