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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/qdt
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.
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
1-888-595-1327. The telephone call is free.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. 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.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-888-369-3615.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/qdt
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/
ACS-1(X)QDRM
FORM
(02-08-2013)
§.$?/¤
OMB No. 0607-0936
13033022
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
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?
Same-sex husband/wife/spouse
Son-in-law or daughter-in-law
Same-sex unmarried partner
Other relative
Biological son or daughter
Roomer or boarder
Adopted son or daughter
Housemate or roommate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
➜ 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.
White
Black, African Am., or Negro
6 What is Person 2’s race? Mark (X) one or more boxes.
White
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
Parent-in-law
Male
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Opposite-sex unmarried partner
3 What is Person 2’s sex? Mark (X) ONE box.
Female
What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Grandchild
Father or mother
What is Person 1’s sex? Mark (X) ONE box.
Male
Opposite-sex husband/wife/spouse
§.$?7¤
Some other race – Print race.
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
13033030
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.
Grandchild
Opposite-sex unmarried partner
Parent-in-law
Opposite-sex unmarried partner
Parent-in-law
Same-sex husband/wife/spouse
Son-in-law or daughter-in-law
Same-sex husband/wife/spouse
Son-in-law or daughter-in-law
Same-sex unmarried partner
Other relative
Same-sex unmarried partner
Other relative
Biological son or daughter
Roomer or boarder
Biological son or daughter
Roomer or boarder
Adopted son or daughter
Housemate or roommate
Adopted son or daughter
Housemate or roommate
Stepson or stepdaughter
Foster child
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Brother or sister
Other nonrelative
Father or mother
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.
Opposite-sex husband/wife/spouse
Age (in years)
5
MI
Opposite-sex husband/wife/spouse
Male
4
First Name
Grandchild
Father or mother
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.
White
Black, African Am., or Negro
6 What is Person 4’s race? Mark (X) one or more boxes.
White
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.
§.$??¤
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on.
Some other race – Print race.
3
13033048
➜
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.
Opposite-sex husband/wife/spouse
Grandchild
Opposite-sex unmarried partner
Parent-in-law
Same-sex husband/wife/spouse
Son-in-law or daughter-in-law
Same-sex unmarried partner
Other relative
Biological son or daughter
Roomer or boarder
Adopted son or daughter
Housemate or roommate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Father or mother
3
4
Male
Female
Age (in years)
Person 7
Last Name (Please print)
Sex
What is Person 5’s sex? Mark (X) ONE box.
Male
Sex
Male
First Name
Female
MI
Age (in years)
Person 8
Female
Last Name (Please print)
First Name
MI
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)
Month
Day
Year of birth
Sex
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Male
Female
Age (in years)
Person 9
Last Name (Please print)
First Name
MI
Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Sex
Male
Female
Age (in years)
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on.
6
Person 10
Last Name (Please print)
First Name
What is Person 5’s race? Mark (X) one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Sex
Male
Female
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)
Person 11
Last Name (Please print)
Sex
Male
First Name
Female
Person 12
Last Name (Please print)
Sex
§.$?Q¤
MI
Age (in years)
First Name
Some other race – Print race.
4
MI
Male
Female
Age (in years)
MI
13033055
Housing
➜
Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.
A
8 Does this house, apartment, or mobile
Answer questions 4 – 6 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 7a.
home have –
Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
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
b. a flush toilet?
4 How many acres is this house or
c. a bathtub or shower?
Less than 1 acre ➔ SKIP to question 6
d. a sink with a faucet?
1 to 9.9 acres
e. a stove or range?
10 or more acres
f. a refrigerator?
g. telephone service from
which you can both make
and receive calls? Include
cell phones.
5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
A building with 3 or 4 apartments
None
A building with 5 to 9 apartments
$1 to $999
A building with 10 to 19 apartments
$1,000 to $2,499
A building with 20 to 49 apartments
$2,500 to $4,999
A building with 50 or more apartments
$5,000 to $9,999
Boat, RV, van, etc.
$10,000 or more
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
b. Handheld computer,
smart mobile phone, or other
handheld wireless computer
6 Is there a business (such as a store or
2
About when was this building first built?
2000 or later – Specify year
No
a. hot and cold running water?
mobile home on?
1
Yes
barber shop) or a medical office on
this property?
c. Some other type of computer
Specify
Yes
No
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier
10 At this house, apartment, or mobile home –
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.
When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month
Year
Yes, with a subscription to an Internet
service
Yes, without a subscription to an Internet
service ➔ SKIP to question 12
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms
3
do you or any member of this household
access the Internet?
7 a. How many separate rooms are in this
No Internet access at this house, apartment,
or mobile home ➔ SKIP to question 12
11 At this house, apartment, or mobile home –
do you or any member of this household
subscribe to the Internet using –
Yes
No
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
a. Dial-up service?
b. DSL service?
c. Cable modem service?
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
§.$?X¤
5
13033063
Housing (continued)
12 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?
14 a. LAST MONTH, what was the cost
of electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars
$
.00
,
None
OR
Included in rent or condominium fee
2
No charge or electricity not used
3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?
5
6 or more
Last month’s cost – Dollars
$
.00
,
13 Which FUEL is used MOST for heating this
OR
house, apartment, or mobile home?
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.
Yes
1
4
15 IN THE PAST 12 MONTHS, did you or
No
16 Is this house, apartment, or mobile home
part of a condominium?
Yes ➔ What is the monthly
condominium fee? For renters,
answer only if you pay the
condominium fee in addition to
your rent; otherwise, mark the
"None" box.
Monthly amount – Dollars
Included in rent or condominium fee
Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP
Included in electricity payment
entered above
No charge or gas not used
$
OR
Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel
No fuel used
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.
Past 12 months’ cost – Dollars
$
.00
,
OR
Included in rent or condominium fee
No charge
.00
,
None
No
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.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented?
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
$
.00
,
OR
Included in rent or condominium fee
No charge or these fuels not used
6
§.$?‘¤
Occupied without payment of
rent? ➔ SKIP to C on the next page
13033071
Housing (continued)
B
Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.
22 a. Do you or any member of this
23 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?
household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?
Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home
equity loan
No ➔ SKIP to D
No ➔ SKIP to question 23a
18 a. What is the monthly rent for this
house, apartment, or mobile home?
Monthly amount – Dollars
$
.00
,
b. Does the monthly rent include any
meals?
No
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?
Amount – Dollars
,
.00
,
20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars
$
Monthly amount – Dollars
,
.00
$
OR
No regular payment required ➔ SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
.00
,
OR
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 .
$
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
$
Yes
C
b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
No regular payment required
D
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .
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.
d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?
Annual costs – Dollars
Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance
$
,
.00
.00
,
E
OR
None
Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 36 for
the mailing instructions.
21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars
$
.00
,
OR
None
§.$?h¤
7
13033089
Person 1
➜
10 a. At any time IN THE LAST 3 MONTHS, has
Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name
First Name
F
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 11
Yes, public school, public college
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.
MI
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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)
Nursery school, preschool
7
Kindergarten
Where was this person born?
Grade 1 through 12 – Specify
grade 1 – 12
In the United States – Print name of state.
13 What is this person’s ancestry or ethnic origin?
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)
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
8
Is this person a citizen of the United States?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
11 What is the highest degree or level of school
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
Yes, U.S. citizen by naturalization – Print year
of naturalization
this person has COMPLETED? Mark (X) ONE box. 14 a. Does this person speak a language other than
If currently enrolled, mark the previous grade or
English at home?
highest degree received.
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Yes
No ➔ SKIP to question 15a
b. What is this language?
Kindergarten
Grade 1 through 11 – Specify
grade 1 – 11
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
No, not a U.S. citizen
Very well
12th grade – NO DIPLOMA
9
When did this person come to live in the
United States? Print numbers in boxes.
HIGH SCHOOL GRADUATE
Regular high school diploma
Well
Not well
Not at all
GED or alternative credential
Year
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)
8
§.$?z¤
ACS-1(X)T(2010)KFI, Page 8, Base (Black)
Page 8, Green Pantone 354 (20, 40, 50 and 100%)
13033097
Person 1 (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)
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
H
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?
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
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
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 13.
Yes
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
No, different house in the United States or
Puerto Rico
No
20 a. What is this person’s current marital status?
Mark (X) ONE box.
Now married ➔ SKIP to question 21
e. TRICARE or other military
health care
b. Where did this person live 1 year ago?
Address (Number and street name)
Widowed
f. VA (including those who have ever
used or enrolled for VA health care)
Divorced
g. Indian Health Service
Never married
Separated
h. Any other type of health insurance
or health coverage plan – Specify C
b. Is this person currently living with a
boyfriend/girlfriend or partner in this
household?
Name of city, town, or post office
Yes
No
17 a. Is this person deaf or does he/she have
Name of U.S. county or
municipio in Puerto Rico
c. Is this person currently in a registered
domestic partnership or civil union?
serious difficulty hearing?
Yes
Yes
No
No
Name of U.S. state or
Puerto Rico
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
ZIP Code
Yes
I
If you marked "Never married" in
question 20a, SKIP to J on the next
page. Otherwise, answer question 21.
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 13.
21 In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
b. Widowed?
c. Divorced?
22 How many times has this person been married?
No
Once
b. Does this person have serious difficulty
walking or climbing stairs?
Two times
Three or more times
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
23 In what year did this person last get married?
Year
No
§.$?¿¤
ACS-1(X)T(2010)KFI, Page 9, Base (Black)
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13033105
Person 1 (continued)
26 Has this person ever served on active duty in
the U.S. Armed Forces, Reserves, or National
Guard? Mark (X) ONE box.
J
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
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Now on active duty
On active duty in the past, but not now
24 Has this person given birth to any children in
at a job (or business)?
Yes ➔ SKIP to question 30
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Yes
No ➔ SKIP to question 35a
the past 12 months?
Yes
29 a. LAST WEEK, did this person work for pay
27 When did this person serve on active duty in
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
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?
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)
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
a. Address (Number and street name)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office
January 1947 to June 1950
Yes
World War II (December 1941 to December 1946)
No ➔ SKIP to question 26
November 1941 or earlier
c. How long has this grandparent been
28 a. Does this person have a VA service-connected
responsible for these grandchildren?
If the grandparent is financially responsible for
disability rating?
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
Yes (such as 0%, 10%, 20%, ... , 100%)
been responsible for the longest period of time.
No ➔ SKIP to question 29a
Less than 6 months
b. What is this person’s service-connected
6 to 11 months
disability rating?
1 or 2 years
0 percent
3 or 4 years
5 or more years
30 At what location did this person work LAST
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
10 or 20 percent
30 or 40 percent
50 or 60 percent
f. ZIP Code
70 percent or higher
10
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ACS-1(X)T(2010)KFI, Page 10, Base (Black)
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13033113
Person 1 (continued)
L
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
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.
No, because of own temporary illness
35 a. LAST WEEK, was this person on layoff from
a job?
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 35c
Streetcar or trolley car
Walked
No
Subway or elevated
Worked at
home ➔ SKIP
to question 39a
Other method
Ferryboat
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
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?
32 How many people, including this person,
Yes ➔ SKIP to question 37
usually rode to work in the car, truck, or van
LAST WEEK?
No
Person(s)
ACTIVELY looking for work?
33 What time did this person usually leave home
to go to work LAST WEEK?
Within the past 12 months
1 to 5 years ago ➔ SKIP to M on the next page
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?
48 to 49 weeks
40 to 47 weeks
Yes
27 to 39 weeks
No ➔ SKIP to question 38
14 to 26 weeks
13 weeks or less
Minute
:
38 When did this person last work, even for a few
50 to 52 weeks
36 During the LAST 4 WEEKS, has this person been
Hour
No, because of all other reasons (in school, etc.)
days?
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Taxicab
K
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
Car, truck, or van
Railroad
37 LAST WEEK, could this person have started a
a.m.
p.m.
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Usual hours worked each WEEK
Minutes
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13033121
Person 1 (continued)
d. Social Security or Railroad Retirement.
45 What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
M
Yes ➔
No
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 Was this person –
Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
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.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
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?
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
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.)
No
Yes ➔
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
No
$
,
.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.
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.
,
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔ $
$
Yes ➔
.00
No
TOTAL AMOUNT for past
12 months
$
,
.00
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
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)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
b. Self-employment income from own nonfarm
48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
.00
Loss
OR $
No
,
,
TOTAL AMOUNT for past
12 months
None
Loss
TOTAL AMOUNT for past
12 months
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
➜
12
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 36 for mailing instructions.
§.$@6¤
ACS-1(X)T(2010)KFI, Page 11, Base (Black)
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13033139
Person 2
➜
10 a. At any time IN THE LAST 3 MONTHS, has
Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name
First Name
F
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 11
Yes, public school, public college
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.
MI
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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)
Nursery school, preschool
7
Kindergarten
Where was this person born?
Grade 1 through 12 – Specify
grade 1 – 12
In the United States – Print name of state.
13 What is this person’s ancestry or ethnic origin?
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)
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
8
Is this person a citizen of the United States?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
11 What is the highest degree or level of school
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
Yes, U.S. citizen by naturalization – Print year
of naturalization
this person has COMPLETED? Mark (X) ONE box. 14 a. Does this person speak a language other than
If currently enrolled, mark the previous grade or
English at home?
highest degree received.
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Yes
No ➔ SKIP to question 15a
b. What is this language?
Kindergarten
Grade 1 through 11 – Specify
grade 1 – 11
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
No, not a U.S. citizen
Very well
12th grade – NO DIPLOMA
9
When did this person come to live in the
United States? Print numbers in boxes.
HIGH SCHOOL GRADUATE
Regular high school diploma
Well
Not well
Not at all
GED or alternative credential
Year
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)
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ACS-1(X)T(2010)KFI, Page 8, Base (Black)
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Page 8, Green Pantone 354 (20, 40, 50 and 100%)
13033147
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)
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
H
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?
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
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
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 18.
Yes
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
No, different house in the United States or
Puerto Rico
No
20 a. What is this person’s current marital status?
Mark (X) ONE box.
Now married ➔ SKIP to question 21
e. TRICARE or other military
health care
b. Where did this person live 1 year ago?
Address (Number and street name)
Widowed
f. VA (including those who have ever
used or enrolled for VA health care)
Divorced
g. Indian Health Service
Never married
Separated
h. Any other type of health insurance
or health coverage plan – Specify C
b. Is this person currently living with a
boyfriend/girlfriend or partner in this
household?
Name of city, town, or post office
Yes
No
17 a. Is this person deaf or does he/she have
Name of U.S. county or
municipio in Puerto Rico
c. Is this person currently in a registered
domestic partnership or civil union?
serious difficulty hearing?
Yes
Yes
No
No
Name of U.S. state or
Puerto Rico
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
ZIP Code
Yes
I
If you marked "Never married" in
question 20a, SKIP to J on the next
page. Otherwise, answer question 21.
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 18.
21 In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
b. Widowed?
c. Divorced?
22 How many times has this person been married?
No
Once
b. Does this person have serious difficulty
walking or climbing stairs?
Two times
Three or more times
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
23 In what year did this person last get married?
Year
No
14
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ACS-1(X)T(2010)KFI, Page 9, Base (Black)
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13033154
Person 2 (continued)
26 Has this person ever served on active duty in
the U.S. Armed Forces, Reserves, or National
Guard? Mark (X) ONE box.
J
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
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Now on active duty
On active duty in the past, but not now
24 Has this person given birth to any children in
at a job (or business)?
Yes ➔ SKIP to question 30
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Yes
No ➔ SKIP to question 35a
the past 12 months?
Yes
29 a. LAST WEEK, did this person work for pay
27 When did this person serve on active duty in
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
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?
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)
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
a. Address (Number and street name)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office
January 1947 to June 1950
Yes
World War II (December 1941 to December 1946)
No ➔ SKIP to question 26
November 1941 or earlier
c. How long has this grandparent been
28 a. Does this person have a VA service-connected
responsible for these grandchildren?
If the grandparent is financially responsible for
disability rating?
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
Yes (such as 0%, 10%, 20%, ... , 100%)
been responsible for the longest period of time.
No ➔ SKIP to question 29a
Less than 6 months
b. What is this person’s service-connected
6 to 11 months
disability rating?
1 or 2 years
0 percent
3 or 4 years
5 or more years
30 At what location did this person work LAST
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
10 or 20 percent
30 or 40 percent
50 or 60 percent
f. ZIP Code
70 percent or higher
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Page 10, Green Pantone 354 (10, 20, 40 and 50%)
13033162
Person 2 (continued)
L
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
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.
No, because of own temporary illness
35 a. LAST WEEK, was this person on layoff from
a job?
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 35c
Streetcar or trolley car
Walked
No
Subway or elevated
Worked at
home ➔ SKIP
to question 39a
Other method
Ferryboat
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
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?
32 How many people, including this person,
Yes ➔ SKIP to question 37
usually rode to work in the car, truck, or van
LAST WEEK?
No
Person(s)
ACTIVELY looking for work?
33 What time did this person usually leave home
to go to work LAST WEEK?
Within the past 12 months
1 to 5 years ago ➔ SKIP to M on the next page
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?
48 to 49 weeks
40 to 47 weeks
Yes
27 to 39 weeks
No ➔ SKIP to question 38
14 to 26 weeks
13 weeks or less
Minute
:
38 When did this person last work, even for a few
50 to 52 weeks
36 During the LAST 4 WEEKS, has this person been
Hour
No, because of all other reasons (in school, etc.)
days?
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Taxicab
K
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
Car, truck, or van
Railroad
37 LAST WEEK, could this person have started a
a.m.
p.m.
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Usual hours worked each WEEK
Minutes
16
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ACS-1(X)T(2010)KFI, Page 11, Base (Black)
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13033170
Person 2 (continued)
d. Social Security or Railroad Retirement.
45 What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
M
Yes ➔
No
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
activities or duties? (For example: patient care,
41 Was this person –
Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
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.
$
Yes ➔
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
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?
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
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.)
No
Yes ➔
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
No
$
,
.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.
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.
,
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔ $
$
Yes ➔
.00
No
TOTAL AMOUNT for past
12 months
$
,
.00
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
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)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
b. Self-employment income from own nonfarm
48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
.00
Loss
OR $
No
,
,
TOTAL AMOUNT for past
12 months
None
Loss
TOTAL AMOUNT for past
12 months
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
➜
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 36 for mailing instructions.
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13033188
Person 3
➜
10 a. At any time IN THE LAST 3 MONTHS, has
Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name
First Name
F
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 11
Yes, public school, public college
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.
MI
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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)
Nursery school, preschool
7
Kindergarten
Where was this person born?
Grade 1 through 12 – Specify
grade 1 – 12
In the United States – Print name of state.
13 What is this person’s ancestry or ethnic origin?
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)
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
8
Is this person a citizen of the United States?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
11 What is the highest degree or level of school
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
Yes, U.S. citizen by naturalization – Print year
of naturalization
this person has COMPLETED? Mark (X) ONE box. 14 a. Does this person speak a language other than
If currently enrolled, mark the previous grade or
English at home?
highest degree received.
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Yes
No ➔ SKIP to question 15a
b. What is this language?
Kindergarten
Grade 1 through 11 – Specify
grade 1 – 11
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
No, not a U.S. citizen
Very well
12th grade – NO DIPLOMA
9
When did this person come to live in the
United States? Print numbers in boxes.
HIGH SCHOOL GRADUATE
Regular high school diploma
Well
Not well
Not at all
GED or alternative credential
Year
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)
18
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13033196
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)
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
H
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?
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
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
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 23.
Yes
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
No, different house in the United States or
Puerto Rico
No
20 a. What is this person’s current marital status?
Mark (X) ONE box.
Now married ➔ SKIP to question 21
e. TRICARE or other military
health care
b. Where did this person live 1 year ago?
Address (Number and street name)
Widowed
f. VA (including those who have ever
used or enrolled for VA health care)
Divorced
g. Indian Health Service
Never married
Separated
h. Any other type of health insurance
or health coverage plan – Specify C
b. Is this person currently living with a
boyfriend/girlfriend or partner in this
household?
Name of city, town, or post office
Yes
No
17 a. Is this person deaf or does he/she have
Name of U.S. county or
municipio in Puerto Rico
c. Is this person currently in a registered
domestic partnership or civil union?
serious difficulty hearing?
Yes
Yes
No
No
Name of U.S. state or
Puerto Rico
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
ZIP Code
Yes
I
If you marked "Never married" in
question 20a, SKIP to J on the next
page. Otherwise, answer question 21.
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 23.
21 In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
b. Widowed?
c. Divorced?
22 How many times has this person been married?
No
Once
b. Does this person have serious difficulty
walking or climbing stairs?
Two times
Three or more times
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
23 In what year did this person last get married?
Year
No
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13033204
Person 3 (continued)
26 Has this person ever served on active duty in
the U.S. Armed Forces, Reserves, or National
Guard? Mark (X) ONE box.
J
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
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Now on active duty
On active duty in the past, but not now
24 Has this person given birth to any children in
at a job (or business)?
Yes ➔ SKIP to question 30
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Yes
No ➔ SKIP to question 35a
the past 12 months?
Yes
29 a. LAST WEEK, did this person work for pay
27 When did this person serve on active duty in
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
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?
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)
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
a. Address (Number and street name)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office
January 1947 to June 1950
Yes
World War II (December 1941 to December 1946)
No ➔ SKIP to question 26
November 1941 or earlier
c. How long has this grandparent been
28 a. Does this person have a VA service-connected
responsible for these grandchildren?
If the grandparent is financially responsible for
disability rating?
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
Yes (such as 0%, 10%, 20%, ... , 100%)
been responsible for the longest period of time.
No ➔ SKIP to question 29a
Less than 6 months
b. What is this person’s service-connected
6 to 11 months
disability rating?
1 or 2 years
0 percent
3 or 4 years
5 or more years
30 At what location did this person work LAST
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
10 or 20 percent
30 or 40 percent
50 or 60 percent
f. ZIP Code
70 percent or higher
20
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13033212
Person 3 (continued)
L
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
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.
No, because of own temporary illness
35 a. LAST WEEK, was this person on layoff from
a job?
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 35c
Streetcar or trolley car
Walked
No
Subway or elevated
Worked at
home ➔ SKIP
to question 39a
Other method
Ferryboat
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
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?
32 How many people, including this person,
Yes ➔ SKIP to question 37
usually rode to work in the car, truck, or van
LAST WEEK?
No
Person(s)
ACTIVELY looking for work?
33 What time did this person usually leave home
to go to work LAST WEEK?
Within the past 12 months
1 to 5 years ago ➔ SKIP to M on the next page
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?
48 to 49 weeks
40 to 47 weeks
Yes
27 to 39 weeks
No ➔ SKIP to question 38
14 to 26 weeks
13 weeks or less
Minute
:
38 When did this person last work, even for a few
50 to 52 weeks
36 During the LAST 4 WEEKS, has this person been
Hour
No, because of all other reasons (in school, etc.)
days?
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Taxicab
K
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
Car, truck, or van
Railroad
37 LAST WEEK, could this person have started a
a.m.
p.m.
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Usual hours worked each WEEK
Minutes
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13033220
Person 3 (continued)
d. Social Security or Railroad Retirement.
45 What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
M
Yes ➔
No
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 Was this person –
Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
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.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
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?
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
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.)
No
Yes ➔
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
No
$
,
.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.
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.
,
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔ $
$
Yes ➔
.00
No
TOTAL AMOUNT for past
12 months
$
,
.00
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
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)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
b. Self-employment income from own nonfarm
48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
.00
Loss
OR $
No
,
,
TOTAL AMOUNT for past
12 months
None
Loss
TOTAL AMOUNT for past
12 months
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
➜
22
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 36 for mailing instructions.
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13033238
Person 4
➜
10 a. At any time IN THE LAST 3 MONTHS, has
Please copy the name of Person 4 from page 3,
then continue answering questions below.
Last Name
First Name
F
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 11
Yes, public school, public college
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.
MI
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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)
Nursery school, preschool
7
Kindergarten
Where was this person born?
Grade 1 through 12 – Specify
grade 1 – 12
In the United States – Print name of state.
13 What is this person’s ancestry or ethnic origin?
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)
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
8
Is this person a citizen of the United States?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
11 What is the highest degree or level of school
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
Yes, U.S. citizen by naturalization – Print year
of naturalization
this person has COMPLETED? Mark (X) ONE box. 14 a. Does this person speak a language other than
If currently enrolled, mark the previous grade or
English at home?
highest degree received.
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Yes
No ➔ SKIP to question 15a
b. What is this language?
Kindergarten
Grade 1 through 11 – Specify
grade 1 – 11
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
No, not a U.S. citizen
Very well
12th grade – NO DIPLOMA
9
When did this person come to live in the
United States? Print numbers in boxes.
HIGH SCHOOL GRADUATE
Regular high school diploma
Well
Not well
Not at all
GED or alternative credential
Year
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)
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13033246
Person 4 (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)
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
H
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?
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
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
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 28.
Yes
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
No, different house in the United States or
Puerto Rico
No
20 a. What is this person’s current marital status?
Mark (X) ONE box.
Now married ➔ SKIP to question 21
e. TRICARE or other military
health care
b. Where did this person live 1 year ago?
Address (Number and street name)
Widowed
f. VA (including those who have ever
used or enrolled for VA health care)
Divorced
g. Indian Health Service
Never married
Separated
h. Any other type of health insurance
or health coverage plan – Specify C
b. Is this person currently living with a
boyfriend/girlfriend or partner in this
household?
Name of city, town, or post office
Yes
No
17 a. Is this person deaf or does he/she have
Name of U.S. county or
municipio in Puerto Rico
c. Is this person currently in a registered
domestic partnership or civil union?
serious difficulty hearing?
Yes
Yes
No
No
Name of U.S. state or
Puerto Rico
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
ZIP Code
Yes
I
If you marked "Never married" in
question 20a, SKIP to J on the next
page. Otherwise, answer question 21.
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 28.
21 In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
b. Widowed?
c. Divorced?
22 How many times has this person been married?
No
Once
b. Does this person have serious difficulty
walking or climbing stairs?
Two times
Three or more times
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
23 In what year did this person last get married?
Year
No
24
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13033253
Person 4 (continued)
26 Has this person ever served on active duty in
the U.S. Armed Forces, Reserves, or National
Guard? Mark (X) ONE box.
J
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
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Now on active duty
On active duty in the past, but not now
24 Has this person given birth to any children in
at a job (or business)?
Yes ➔ SKIP to question 30
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Yes
No ➔ SKIP to question 35a
the past 12 months?
Yes
29 a. LAST WEEK, did this person work for pay
27 When did this person serve on active duty in
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
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?
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)
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
a. Address (Number and street name)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office
January 1947 to June 1950
Yes
World War II (December 1941 to December 1946)
No ➔ SKIP to question 26
November 1941 or earlier
c. How long has this grandparent been
28 a. Does this person have a VA service-connected
responsible for these grandchildren?
If the grandparent is financially responsible for
disability rating?
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
Yes (such as 0%, 10%, 20%, ... , 100%)
been responsible for the longest period of time.
No ➔ SKIP to question 29a
Less than 6 months
b. What is this person’s service-connected
6 to 11 months
disability rating?
1 or 2 years
0 percent
3 or 4 years
5 or more years
30 At what location did this person work LAST
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
10 or 20 percent
30 or 40 percent
50 or 60 percent
f. ZIP Code
70 percent or higher
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Person 4 (continued)
L
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
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.
No, because of own temporary illness
35 a. LAST WEEK, was this person on layoff from
a job?
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 35c
Streetcar or trolley car
Walked
No
Subway or elevated
Worked at
home ➔ SKIP
to question 39a
Other method
Ferryboat
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
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?
32 How many people, including this person,
Yes ➔ SKIP to question 37
usually rode to work in the car, truck, or van
LAST WEEK?
No
Person(s)
ACTIVELY looking for work?
33 What time did this person usually leave home
to go to work LAST WEEK?
Within the past 12 months
1 to 5 years ago ➔ SKIP to M on the next page
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?
48 to 49 weeks
40 to 47 weeks
Yes
27 to 39 weeks
No ➔ SKIP to question 38
14 to 26 weeks
13 weeks or less
Minute
:
38 When did this person last work, even for a few
50 to 52 weeks
36 During the LAST 4 WEEKS, has this person been
Hour
No, because of all other reasons (in school, etc.)
days?
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Taxicab
K
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
Car, truck, or van
Railroad
37 LAST WEEK, could this person have started a
a.m.
p.m.
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Usual hours worked each WEEK
Minutes
26
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Person 4 (continued)
d. Social Security or Railroad Retirement.
45 What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
M
Yes ➔
No
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 Was this person –
Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
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.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
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?
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
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.)
No
Yes ➔
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
No
$
,
.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.
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.
,
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔ $
$
Yes ➔
.00
No
TOTAL AMOUNT for past
12 months
$
,
.00
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
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)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
b. Self-employment income from own nonfarm
48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
.00
Loss
OR $
No
,
,
TOTAL AMOUNT for past
12 months
None
Loss
TOTAL AMOUNT for past
12 months
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
➜
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 36 for mailing instructions.
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Person 5
➜
10 a. At any time IN THE LAST 3 MONTHS, has
Please copy the name of Person 5 from page 4,
then continue answering questions below.
Last Name
First Name
F
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 11
Yes, public school, public college
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.
MI
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
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)
Nursery school, preschool
7
Kindergarten
Where was this person born?
Grade 1 through 12 – Specify
grade 1 – 12
In the United States – Print name of state.
13 What is this person’s ancestry or ethnic origin?
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)
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
8
Is this person a citizen of the United States?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
11 What is the highest degree or level of school
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
Yes, U.S. citizen by naturalization – Print year
of naturalization
this person has COMPLETED? Mark (X) ONE box. 14 a. Does this person speak a language other than
If currently enrolled, mark the previous grade or
English at home?
highest degree received.
NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Yes
No ➔ SKIP to question 15a
b. What is this language?
Kindergarten
Grade 1 through 11 – Specify
grade 1 – 11
For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
No, not a U.S. citizen
Very well
12th grade – NO DIPLOMA
9
When did this person come to live in the
United States? Print numbers in boxes.
HIGH SCHOOL GRADUATE
Regular high school diploma
Well
Not well
Not at all
GED or alternative credential
Year
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)
28
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Person 5 (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)
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
H
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?
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
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
Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 36.
Yes
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
No, different house in the United States or
Puerto Rico
No
20 a. What is this person’s current marital status?
Mark (X) ONE box.
Now married ➔ SKIP to question 21
e. TRICARE or other military
health care
b. Where did this person live 1 year ago?
Address (Number and street name)
Widowed
f. VA (including those who have ever
used or enrolled for VA health care)
Divorced
g. Indian Health Service
Never married
Separated
h. Any other type of health insurance
or health coverage plan – Specify C
b. Is this person currently living with a
boyfriend/girlfriend or partner in this
household?
Name of city, town, or post office
Yes
No
17 a. Is this person deaf or does he/she have
Name of U.S. county or
municipio in Puerto Rico
c. Is this person currently in a registered
domestic partnership or civil union?
serious difficulty hearing?
Yes
Yes
No
No
Name of U.S. state or
Puerto Rico
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
ZIP Code
Yes
I
If you marked "Never married" in
question 20a, SKIP to J on the next
page. Otherwise, answer question 21.
No
G
Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 36.
21 In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
18 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
Yes
b. Widowed?
c. Divorced?
22 How many times has this person been married?
No
Once
b. Does this person have serious difficulty
walking or climbing stairs?
Two times
Three or more times
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
23 In what year did this person last get married?
Year
No
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Person 5 (continued)
26 Has this person ever served on active duty in
the U.S. Armed Forces, Reserves, or National
Guard? Mark (X) ONE box.
J
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
Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.
Now on active duty
On active duty in the past, but not now
24 Has this person given birth to any children in
at a job (or business)?
Yes ➔ SKIP to question 30
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Yes
No ➔ SKIP to question 35a
the past 12 months?
Yes
29 a. LAST WEEK, did this person work for pay
27 When did this person serve on active duty in
No
25 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26
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?
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)
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
a. Address (Number and street name)
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Korean War (July 1950 to January 1955)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
b. Name of city, town, or post office
January 1947 to June 1950
Yes
World War II (December 1941 to December 1946)
No ➔ SKIP to question 26
November 1941 or earlier
c. How long has this grandparent been
28 a. Does this person have a VA service-connected
responsible for these grandchildren?
If the grandparent is financially responsible for
disability rating?
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
Yes (such as 0%, 10%, 20%, ... , 100%)
been responsible for the longest period of time.
No ➔ SKIP to question 29a
Less than 6 months
b. What is this person’s service-connected
6 to 11 months
disability rating?
1 or 2 years
0 percent
3 or 4 years
5 or more years
30 At what location did this person work LAST
c. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
d. Name of county
e. Name of U.S. state or foreign country
10 or 20 percent
30 or 40 percent
50 or 60 percent
f. ZIP Code
70 percent or higher
30
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Person 5 (continued)
L
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39a.
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.
No, because of own temporary illness
35 a. LAST WEEK, was this person on layoff from
a job?
Motorcycle
Bus or trolley bus
Bicycle
Yes ➔ SKIP to question 35c
Streetcar or trolley car
Walked
No
Subway or elevated
Worked at
home ➔ SKIP
to question 39a
Other method
Ferryboat
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
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?
32 How many people, including this person,
Yes ➔ SKIP to question 37
usually rode to work in the car, truck, or van
LAST WEEK?
No
Person(s)
ACTIVELY looking for work?
33 What time did this person usually leave home
to go to work LAST WEEK?
Within the past 12 months
1 to 5 years ago ➔ SKIP to M on the next page
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?
48 to 49 weeks
40 to 47 weeks
Yes
27 to 39 weeks
No ➔ SKIP to question 38
14 to 26 weeks
13 weeks or less
Minute
:
38 When did this person last work, even for a few
50 to 52 weeks
36 During the LAST 4 WEEKS, has this person been
Hour
No, because of all other reasons (in school, etc.)
days?
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Taxicab
K
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
Car, truck, or van
Railroad
37 LAST WEEK, could this person have started a
a.m.
p.m.
40 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Usual hours worked each WEEK
Minutes
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Person 5 (continued)
d. Social Security or Railroad Retirement.
45 What kind of work was this person doing?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
M
Yes ➔
No
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
41 Was this person –
Mark (X) ONE box.
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)
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.
$
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
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?
42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
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.)
No
Yes ➔
If net income was a loss, mark the "Loss" box to
the right of the dollar amount.
No
$
,
.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.
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.
,
.00
,
g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔ $
$
Yes ➔
.00
No
TOTAL AMOUNT for past
12 months
$
,
.00
TOTAL AMOUNT for past
12 months
Name of company, business, or other employer
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)
44 Is this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
b. Self-employment income from own nonfarm
48 What was this person’s total income during the
businesses or farm businesses, including
PAST 12 MONTHS? Add entries in questions 47a
proprietorships and partnerships. Report
to 47h; subtract any losses. If net income was a loss,
NET income after business expenses.
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
.00
Yes ➔ $
,
,
.00
Loss
OR $
No
,
,
TOTAL AMOUNT for past
12 months
None
Loss
TOTAL AMOUNT for past
12 months
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
➜
32
Now continue with the mailing instructions
on page 36.
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34
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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
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 0607-0936, 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
0607-0936" 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)QDRM (02-08-2013)
36
§.$B]¤
ACS-1(X)T(2010)KFI, Page 28, Base (Black)
Page 28, Green Pantone 354 (20, 40 and 50%)
| File Type | application/pdf |
| File Modified | 2013-02-08 |
| File Created | 2013-02-06 |