Paper Group 3 Verion 2

13026018

Attachment X: ACS Respondent Burden Testing Paper Survey Instrument: Group 3, Version 1

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.

➜

Please print today’s date.
Month
Day
Year

➜

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

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.

MI

First Name

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 completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

ACS-1(X)G3V2

FORM
(03-24-2016) Draft 1

§.#]3¤

OMB No. 0607-0810
OMB No. 0607-0936

13026026

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. 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 or African Am.

Black or African Am.

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

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. C

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

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

Some other race – Print race. C

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

§.#];¤

Some other race – Print race. C

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

13026034

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.
Female

Male

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. 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 or African Am.

Black or African Am.

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

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. C

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

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

Some other race – Print race. C

§.#]C¤

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

Some other race – Print race. C

3

13026042

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

Female

Age (in years)

Person 8

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

Male

Month

Day

Last Name (Please print)

First Name

MI

Year of birth

Sex

Male

Female

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

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

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. C

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

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. C

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

Age (in years)

Sex

Male

First Name

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race. C
Sex

4

§.#]K¤

MI

Male

Female

Age (in years)

MI

13026059

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
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

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

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

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

c. How well does this person speak English?

GED or alternative credential

Very well

COLLEGE OR SOME COLLEGE

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

Well

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

For example: Korean, Italian, Spanish, Vietnamese

Not well
Not at all

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

Person is under 1 year old ➔ SKIP to page 7

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)

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Yes, this house
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page

Doctorate degree (for example: PhD, EdD)

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

F

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

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

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

Address (Number and street name)

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.

No, different house in the United States or
Puerto Rico

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)

City

Nursery school, preschool
Kindergarten

State

ZIP

Grade 1 through 12 – Specify
grade 1 – 12
County
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

13026067

Person 1 (continued)

J

29 a. LAST WEEK, did this person work for pay

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

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

WEEK? If this person worked at more than one
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?
a.m.
p.m.

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

b. City

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

39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?

K

c. State or foreign country

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

d. ZIP

40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. County

No

f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39

Ferryboat

Other method

Taxicab

6

Usual hours worked each WEEK

§.#]d¤

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

ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks

13026075

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
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

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

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

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

c. How well does this person speak English?

GED or alternative credential

Very well

COLLEGE OR SOME COLLEGE

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

Well

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

For example: Korean, Italian, Spanish, Vietnamese

Not well
Not at all

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

Person is under 1 year old ➔ SKIP to page 9

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)

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Yes, this house ➔ SKIP to next page
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page

Doctorate degree (for example: PhD, EdD)

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

F

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

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

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

Address (Number and street name)

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.

No, different house in the United States or
Puerto Rico

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)

City

Nursery school, preschool
Kindergarten

State

ZIP

Grade 1 through 12 – Specify
grade 1 – 12
County
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)

§.#]l¤

7

13026083

Person 2 (continued)

J

29 a. LAST WEEK, did this person work for pay

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

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

WEEK? If this person worked at more than one
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?
a.m.
p.m.

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

b. City

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

39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?

K

c. State or foreign country

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

d. ZIP

40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. County

No

f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39

Ferryboat

Other method

Taxicab

8

Usual hours worked each WEEK

§.#]t¤

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

ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks

13026091

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
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

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

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

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a

c. How well does this person speak English?

GED or alternative credential

Very well

COLLEGE OR SOME COLLEGE

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

Well

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

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

1 or more years of college credit, no degree

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

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE

No, not a U.S. citizen

9

For example: Korean, Italian, Spanish, Vietnamese

Not well
Not at all

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

Person is under 1 year old ➔ SKIP to page 11

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)

When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.

Year

Yes, this house ➔ SKIP to next page
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page

Doctorate degree (for example: PhD, EdD)

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

F

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

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

b. Where did this person live 1 year ago?

No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college

Address (Number and street name)

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.

No, different house in the United States or
Puerto Rico

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)

City

Nursery school, preschool
Kindergarten

State

ZIP

Grade 1 through 12 – Specify
grade 1 – 12
County
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)

§.#]|¤

9

13026109

Person 3 (continued)

J

29 a. LAST WEEK, did this person work for pay

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

at a job (or business)?

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

Yes ➔ SKIP to question 30
No – Did not work (or retired)

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

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

Yes

Yes, could have gone to work

No ➔ SKIP to question 35a

No, because of own temporary illness

30 At what location did this person work LAST

33 What time did this person usually leave home

WEEK? If this person worked at more than one
location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

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

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?
a.m.
p.m.

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

b. City

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

39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?

K

c. State or foreign country

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

d. ZIP

40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

e. County

No

f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits

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

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van

Motorcycle

Bus or trolley bus

Bicycle

Streetcar or trolley car

Walked

Subway or elevated
Railroad

Worked at
home ➔ SKIP
to question 39

Ferryboat

Other method

Taxicab

10

Usual hours worked each WEEK

§.#^*¤

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

ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks

13026117

Mailing
Instructions
➜ Please make sure you have...

• listed all names and answered the questions on
pages 2, 3, and 4
• answered all Person questions for each person.
➜ Then...

• put the completed questionnaire into the postage-paid
return envelope. If the envelope has been misplaced,
please mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your address shows
in the window of the return envelope.
Thank you for participating in
the American Community Survey.

For Census Bureau Use
POP

EDIT

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 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 and 0607-0936,
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 and 0607-0936" 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)G3V2 (03-24-2016)

§.#^2¤

11