Various Economic Area Pretesting Activities

Generic Clearance for Questionnaire Pretesting Research

omb1317SBO_enc4

Various Economic Area Pretesting Activities

OMB: 0607-0725

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0725 can be found here:

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10022010

4
U.S. DEPARTMENT OF COMMERCE

Owner 3

Owner 4

Economics and Statistics Administration

U.S. CENSUS BUREAU

Please answer the following questions about Owner 3
listed in 5 on Page 2.

Please answer the following questions about Owner 4
listed in 5 on Page 2.

15 What is the sex of Owner 3?

19 What is the sex of Owner 4?
Female

Male

this survey, Hispanic origins are not races.
16 Is Owner 3 of Hispanic, Latino or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

Yes, Mexican, Mexican Am.,
Yes, Cuban
Chicano
Yes, another Hispanic, Latino, or Spanish origin - Print
origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

17 What is Owner 3’s race? Mark ✘ all that apply.
White

Black or African Am.

this survey, Hispanic origins are not races.
20 Is Owner 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

White

Black or African Am.

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or
Chamorro

Samoan

Filipino

Vietnamese

Samoan

Other Pacific
Islander - Print

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

Chinese

Korean

Guamanian or
Chamorro

Filipino

Vietnamese

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

race, for example,
Fijian, Tongan,
and so on. C

Some other race - Print race C

18 A. Has Owner 3 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?
Yes

B. (If Yes) Do any of the following characteristics describe
Owner 3’s military service? Mark ✘ all that apply.

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

Some other race - Print race C

22 A. Has Owner 4 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?
Yes

B. (If Yes) Do any of the following characteristics describe
Owner 4’s military service? Mark ✘ all that apply.

YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, requires businesses and other organizations
that receive this questionnaire to answer the questions and return the report to the U.S. Census Bureau. By the same
law, YOUR CENSUS REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality
of Census Bureau information and may be used only for statistical purposes. Further, copies retained in respondents’
files are immune from legal process.

COMPLETE THIS SURVEY ONLINE
• Go to: econhelp.census.gov/sbo
• Log in using the ID and password listed above.
Or mail your completed form to:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001

Why did I receive this survey?
We are surveying small and large companies,
self-employed people, and people working for
others as nonemployees or independent
contractors. Your responses will help us produce
reliable information about the U.S. economy.

Served on active duty military service, not including
training for the Reserves or National Guard

Am I self-employed?

Disabled as the result of illness or injury incurred
or aggravated during military service

Yes, if you earned income working for yourself or
for someone else as a nonemployee during 2012.

Served on active duty military service after
September 11, 2001

Need help or have questions?

Served on active duty military service in 2012

Served in the National Guard or as a reservist of
any branch of the U.S. Armed Forces in 2012

None of the above

Please return the completed original questionnaire in the postage-paid envelope. Make sure the
barcode above your address shows in the window of the envelope. Please make a photocopy of
this form for your records. If the envelope has been misplaced, please mail the form to:

➤

• Visit econhelp.census.gov/sbo
• Call 1-888-824-9954, between 8 a.m. and 6 p.m.,
Eastern time, Monday through Friday.

INSTRUCTIONS
Please read the enclosed insert before
answering the questions.
• Use blue or black ink.
• Place an "✘" inside the box. ✘
• Center numbers in boxes.
7 0
• Do not put slashes through 0 or 7.
1 Please PRINT the first and last name of the person
who is filling out this form.
Contact Name

Include today’s date and a telephone number so we
can contact you if there is a question.

Area code

YYYY

Number

¿Necesita ayuda?

23 Thank you for participating in the Survey of Business Owners and Self-Employed Persons.

FORM SBO-2

OPY
C
N
O
I
T
A
INFORM SE TO REPORT
U
DO NOT

21 What is Owner 4’s race? Mark ✘ all that apply.

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

Native Hawaiian

OMB No. 0607-0943: Approval Expires 11/30/2015

(11/13/2012)

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For

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

Japanese

SBO-2

Female

Male

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For

FORM

2012 SURVEY OF BUSINESS OWNERS AND
SELF-EMPLOYED PERSONS

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001

Si usted habla español y necesita ayuda para
completar su cuestionario, Ilame sin cargo alguno
al 1-888-824-9954, entre las 8 a.m. y las 6 p.m., hora
del Este, de lunes a viernes.

Extension

§+#5+¤

10022028

2
Please answer the following questions for the person(s)
or business named in the mailing label. Answer even
if the business has been sold, reorganized, or ceased
operation.

5 For the person(s) owning the largest percentage(s)
in this business as of December 31, 2012, please list
the percentage owned by each person and his or her
position title.
• Do not report percentages owned by parent

You may use estimates if this form requests information
that is not available in your business records.

companies, estates, trusts, or other entities.
select any 4 people.

7 What is the sex of Owner 1?

report 1/3 ownership as 33.0%.

worked as a consultant or an independent
contractor.

Male

Female

Male

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For
9

Position Title

(Estimates are
acceptable)

(Example: sole owner, co-owner,
shareholder, president,
vice president, etc.)

• Do not combine two or more owners to create one

owner.
Owner 1:

.0 %

Owner 2:

.0 %

Owner 3:

.0 %

Owner 4:

.0 %

No, not of Hispanic,
Latino, or Spanish origin

Female

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For
12

this survey, Hispanic origins are not races.
8 Is Owner 1 of Hispanic, Latino or Spanish origin?

Percentage Owned

Please answer the following questions about Owner 2
listed in 5 on Page 2.
11 What is the sex of Owner 2?

• Round percentages to whole numbers. For example,

• Include yourself if you were a sole proprietor or

Owner 2

Please answer the following questions about Owner 1
listed in 5 on Page 2.

• If more than 4 people owned this business equally,

2 On December 31, 2012, how many people owned this
business?

• Count spouses and partners as separate owners.

Owner 1

this survey, Hispanic origins are not races.
12 Is Owner 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

1 person

Go to 5 .

2 – 4 people

9 What is Owner 1’s race? Mark ✘ all that apply.

5 – 10 people

White

Go to 3 .

NOTE: Do not list more than 4 owners.

Don’t know

3 On December 31, 2012, was this business owned by
a government or tribal entity?
Yes

A. In 2012, did two or more members of one
family own the majority of this business?
(Family refers to spouses, parents/guardians,
children, siblings, or close relatives.)
Yes

4 On December 31, 2012, did any one person own
10% or more of this business?
Yes
No – Go to 23 on page 4 ONLY if no person
owned 10% or more of this business.

White

Black or African Am.

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

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

No ➜ Go to 7 .

race, for example,
Fijian, Tongan,
and so on. C

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

B. (If Yes) Did spouses jointly own this business?
Yes

C. (If Yes) Was this business operated equally by both
spouses?

No, primarily operated by Owner 1

Some other race - Print race C

No ➜ Go to 7 .

10 A. Has Owner 1 ever served in any branch of the U.S.

14 A. Has Owner 2 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?

Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?

Yes, equally operated by spouses

Yes

Served on active duty military service, not including
training for the Reserves or National Guard

Disabled as the result of illness or injury incurred
or aggravated during military service

Served on active duty military service after
September 11, 2001

Served on active duty military service in 2012

Served in the National Guard or as a reservist of
any branch of the U.S. Armed Forces in 2012

None of the above

➜
FORM SBO-2

B. (If Yes) Do any of the following characteristics describe
Owner 2’s military service? Mark ✘ all that apply.

B. (If Yes) Do any of the following characteristics describe
Owner 1’s military service? Mark ✘ all that apply.

No, primarily operated by Owner 2

FORM SBO-2

Black or African Am.

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

11 or more people
Business is owned by a
parent company, estate,
trust, or other entity.

13 What is Owner 2’s race? Mark ✘ all that apply.

Please turn to the next page to continue.

§+#5=¤

10022028

2
Please answer the following questions for the person(s)
or business named in the mailing label. Answer even
if the business has been sold, reorganized, or ceased
operation.

You may use estimates if this form requests information
that is not available in your business records.

companies, estates, trusts, or other entities.
select any 4 people.

7 What is the sex of Owner 1?

report 1/3 ownership as 33.0%.

worked as a consultant or an independent
contractor.

Male

Female

Male

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For
9

Position Title

(Estimates are
acceptable)

(Example: sole owner, co-owner,
shareholder, president,
vice president, etc.)

• Do not combine two or more owners to create one

owner.
Owner 1:

.0 %

Owner 2:

.0 %

Owner 3:

.0 %

Owner 4:

.0 %

No, not of Hispanic,
Latino, or Spanish origin

Female

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For
12

this survey, Hispanic origins are not races.
8 Is Owner 1 of Hispanic, Latino or Spanish origin?

Percentage Owned

Please answer the following questions about Owner 2
listed in 5 on Page 2.
11 What is the sex of Owner 2?

• Round percentages to whole numbers. For example,

• Include yourself if you were a sole proprietor or

Owner 2

Please answer the following questions about Owner 1
listed in 5 on Page 2.

• If more than 4 people owned this business equally,

2 On December 31, 2012, how many people owned this
business?

• Count spouses and partners as separate owners.

Owner 1

this survey, Hispanic origins are not races.
12 Is Owner 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

1 person

Go to 5 .

2 – 4 people

9 What is Owner 1’s race? Mark ✘ all that apply.

5 – 10 people

White

Go to 3 .

NOTE: Do not list more than 4 owners.

Don’t know

3 On December 31, 2012, was this business owned by
a government or tribal entity?
Yes

A. In 2012, did two or more members of one
family own the majority of this business?
(Family refers to spouses, parents/guardians,
children, siblings, or close relatives.)
Yes

4 On December 31, 2012, did any one person own
10% or more of this business?
Yes
No – Go to 23 on page 4 ONLY if no person
owned 10% or more of this business.

White

Black or African Am.

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

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

No ➜ Go to 7 .

race, for example,
Fijian, Tongan,
and so on. C

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

B. (If Yes) Did spouses jointly own this business?
Yes

C. (If Yes) Was this business operated equally by both
spouses?

No, primarily operated by Owner 1

Some other race - Print race C

No ➜ Go to 7 .

10 A. Has Owner 1 ever served in any branch of the U.S.

14 A. Has Owner 2 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?

Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?

Yes, equally operated by spouses

Yes

Served on active duty military service, not including
training for the Reserves or National Guard

Disabled as the result of illness or injury incurred
or aggravated during military service

Served on active duty military service after
September 11, 2001

Served on active duty military service in 2012

Served in the National Guard or as a reservist of
any branch of the U.S. Armed Forces in 2012

None of the above

➜
FORM SBO-2

B. (If Yes) Do any of the following characteristics describe
Owner 2’s military service? Mark ✘ all that apply.

B. (If Yes) Do any of the following characteristics describe
Owner 1’s military service? Mark ✘ all that apply.

No, primarily operated by Owner 2

FORM SBO-2

Black or African Am.

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

11 or more people
Business is owned by a
parent company, estate,
trust, or other entity.

13 What is Owner 2’s race? Mark ✘ all that apply.

Please turn to the next page to continue.

§+#5=¤

10022010

4
U.S. DEPARTMENT OF COMMERCE

Owner 3

Owner 4

Economics and Statistics Administration

U.S. CENSUS BUREAU

Please answer the following questions about Owner 3
listed in 5 on Page 2.

Please answer the following questions about Owner 4
listed in 5 on Page 2.

15 What is the sex of Owner 3?

19 What is the sex of Owner 4?
Female

Male

this survey, Hispanic origins are not races.
16 Is Owner 3 of Hispanic, Latino or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

17 What is Owner 3’s race? Mark ✘ all that apply.
White

Black or African Am.

this survey, Hispanic origins are not races.
20 Is Owner 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic,
Latino, or Spanish origin

Yes, Puerto Rican

21 What is Owner 4’s race? Mark ✘ all that apply.
White

Black or African Am.

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

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or
Chamorro

Samoan

Filipino

Vietnamese

Samoan

Other Pacific
Islander - Print

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

Native Hawaiian

Chinese

Korean

Guamanian or
Chamorro

Filipino

Vietnamese

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

race, for example,
Fijian, Tongan,
and so on. C

Some other race - Print race C

18 A. Has Owner 3 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?
Yes

B. (If Yes) Do any of the following characteristics describe
Owner 3’s military service? Mark ✘ all that apply.

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

Some other race - Print race C

22 A. Has Owner 4 ever served in any branch of the U.S.
Armed Forces, including the Coast Guard, the National
Guard, or a Reserve component of any service branch?
Yes

B. (If Yes) Do any of the following characteristics describe
Owner 4’s military service? Mark ✘ all that apply.

Served on active duty military service, not including
training for the Reserves or National Guard

Am I self-employed?

Disabled as the result of illness or injury incurred
or aggravated during military service

Yes, if you earned income working for yourself or
for someone else as a nonemployee during 2012.

Served on active duty military service after
September 11, 2001

Need help or have questions?

Served on active duty military service in 2012

Served in the National Guard or as a reservist of
any branch of the U.S. Armed Forces in 2012

None of the above

➤

• Visit econhelp.census.gov/sbo
• Call 1-888-824-9954, between 8 a.m. and 6 p.m.,
Eastern time, Monday through Friday.

Include today’s date and a telephone number so we
can contact you if there is a question.

Area code

YYYY

Number

¿Necesita ayuda?

23 Thank you for participating in the Survey of Business Owners and Self-Employed Persons.

FORM SBO-2

OMB No. 0607-0943: Approval Expires 11/30/2015

(11/13/2012)

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For

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

Japanese

SBO-2

Female

Male

Please answer BOTH Question
about
☞ NOTE:
Hispanic origin and Question
about race. For

FORM

2012 SURVEY OF BUSINESS OWNERS AND
SELF-EMPLOYED PERSONS

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001

Si usted habla español y necesita ayuda para
completar su cuestionario, Ilame sin cargo alguno
al 1-888-824-9954, entre las 8 a.m. y las 6 p.m., hora
del Este, de lunes a viernes.

Extension

§+#5+¤

File Type	application/pdf
File Modified	2013-07-15
File Created	2012-12-05