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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/acs
OR
Complete this form and mail it
back as soon as possible.
➜
Please print today’s date.
Month
➜
Day
Year
Please print the name and telephone number of the person who is
filling out this form. We will only contact you if needed for official
Census Bureau business.
Last Name
This form asks for information about the
people who are living or staying at the
address on the mailing label and about the
house, apartment, or mobile home located
at the address on the mailing label.
MI
First Name
Area Code + Number
If you need help or have questions
about completing this form, please call
1-800-354-7271. The telephone call is free.
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 1-877-833-5625.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs
ACS-1(X)IWW
FORM
(10-06-2016) Draft 3
§.#g1¤
OMB No. 0607-0810
OMB No. 0607-0936
13027024
Person 1
Person 2
1 What is Person 2’s name?
(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1?
X
3
Person 1
4
Female
Month
Day
Year of birth
Question 6 about race. For this survey, Hispanic origins are not races.
6
Is Person 1 of Hispanic, Latino, or Spanish origin?
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
What is Person 1’s race? Mark (X) one or more boxes.
6 What is Person 2’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
2
Adopted son or daughter
Male
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Other relative
3 What is Person 2’s sex? Mark (X) ONE box.
What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Son-in-law or daughter-in-law
Biological son or daughter
Parent-in-law
What is Person 1’s sex? Mark (X) ONE box.
Male
Husband or wife
§.#g9¤
Some other race – Print race. C
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
13027032
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Other relative
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Female
Male
What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
6
2 How is this person related to Person 1? Mark (X) ONE box.
Son-in-law or daughter-in-law
Age (in years)
5
MI
Biological son or daughter
Male
4
First Name
Husband or wife
Parent-in-law
3
Last Name (Please print)
Is Person 3 of Hispanic, Latino, or Spanish origin?
Female
4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Yes, Cuban
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
What is Person 3’s race? Mark (X) one or more boxes.
6 What is Person 4’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
§.#gA¤
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Some other race – Print race. C
3
13027040
Person 5
1
➜
What is Person 5’s name?
Last Name (Please print)
First Name
MI
If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.
Person 6
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
3
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Sex
Female
Female
Age (in years)
Person 8
What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Male
Month
Day
Last Name (Please print)
First Name
MI
Year of birth
Sex
Male
Female
Age (in years)
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5
Is Person 5 of Hispanic, Latino, or Spanish origin?
Person 9
Last Name (Please print)
First Name
MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Sex
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Male
Female
Person 10
Last Name (Please print)
6
Age (in years)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Male
Female
Person 11
Last Name (Please print)
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Age (in years)
Sex
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race. C
Sex
4
§.#gI¤
MI
Male
Female
Age (in years)
MI
13027107
Person 1
➜
J
Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
32 How many people, including this person,
First Name
usually rode to work in the car, truck, or van
LAST WEEK?
MI
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
30 a. LAST WEEK, did this person work for pay
No, because of own temporary illness
at a job (or business)?
33 What time did this person usually leave home
Yes ➔ SKIP to question 31
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
No – Did not work (or retired)
Hour
Minute
:
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
a.m.
p.m.
Yes
34 How many minutes did it usually take this
No ➔ SKIP to question 35a
person to get from home to work LAST WEEK?
Minutes
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47
39 During the 52 weeks covering 2015, that is from
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
38 When did this person last work, even for a few
January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No
Usual hours worked each WEEK
40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
10
§.#h(¤
b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks
13027115
Person 1 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
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.
45 What kind of work was this person doing?
f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.
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)
Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.
41 Was this person –
Mark (X) ONE box.
47 INCOME RECEIVED IN 2015
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
Consider income received from January 1, 2015 to
December 31, 2015.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.
a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?
a Federal GOVERNMENT employee?
Yes
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
No
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.
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)
Yes
No
48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.
b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.
If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.
Yes
For income received jointly, include the appropriate
share for this person in the total.
No
Loss
If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.
c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.
OR
None
$
,
,
TOTAL AMOUNT for 2015
.00
Loss
Yes
No
Loss
44 Is this mainly – Mark (X) ONE box.
manufacturing?
d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No
§.#h0¤
➜
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 28 for mailing instructions.
11
13027149
Person 2
➜
J
Please copy the name of Person 2 from page
2,then continue answering questions below.
Last Name
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
32 How many people, including this person,
First Name
usually rode to work in the car, truck, or van
LAST WEEK?
MI
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
30 a. LAST WEEK, did this person work for pay
No, because of own temporary illness
at a job (or business)?
33 What time did this person usually leave home
Yes ➔ SKIP to question 31
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
No – Did not work (or retired)
Hour
Minute
:
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
a.m.
p.m.
Yes
34 How many minutes did it usually take this
No ➔ SKIP to question 35a
person to get from home to work LAST WEEK?
Minutes
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47
39 During the 52 weeks covering 2015, that is from
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
38 When did this person last work, even for a few
January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No
Usual hours worked each WEEK
40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
14
§.#hR¤
b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks
13027156
Person 2 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
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.
45 What kind of work was this person doing?
f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.
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)
Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.
41 Was this person –
Mark (X) ONE box.
47 INCOME RECEIVED IN 2015
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
Consider income received from January 1, 2015 to
December 31, 2015.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.
a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?
a Federal GOVERNMENT employee?
Yes
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
No
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.
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)
Yes
No
48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.
b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.
If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.
Yes
For income received jointly, include the appropriate
share for this person in the total.
No
Loss
If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.
c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.
OR
None
$
,
,
TOTAL AMOUNT for 2015
.00
Loss
Yes
No
Loss
44 Is this mainly – Mark (X) ONE box.
manufacturing?
d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No
§.#hY¤
➜
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 28 for mailing instructions.
15
13027180
Person 3
➜
J
Please copy the name of Person 3 from page
3,then continue answering questions below.
Last Name
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
32 How many people, including this person,
First Name
usually rode to work in the car, truck, or van
LAST WEEK?
MI
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work
30 a. LAST WEEK, did this person work for pay
No, because of own temporary illness
at a job (or business)?
33 What time did this person usually leave home
Yes ➔ SKIP to question 31
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
No – Did not work (or retired)
Hour
Minute
:
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
a.m.
p.m.
Yes
34 How many minutes did it usually take this
No ➔ SKIP to question 35a
person to get from home to work LAST WEEK?
Minutes
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47
39 During the 52 weeks covering 2015, that is from
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
38 When did this person last work, even for a few
January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?
K
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No
Usual hours worked each WEEK
40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
18
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b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks
13027198
Person 3 (continued)
L
Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.
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.
45 What kind of work was this person doing?
f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)
Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.
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)
Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.
41 Was this person –
Mark (X) ONE box.
47 INCOME RECEIVED IN 2015
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?
Consider income received from January 1, 2015 to
December 31, 2015.
an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.
a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?
a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?
a Federal GOVERNMENT employee?
Yes
SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?
No
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.
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)
Yes
No
48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.
b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.
If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.
Yes
For income received jointly, include the appropriate
share for this person in the total.
No
Loss
If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.
c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.
OR
None
$
,
,
TOTAL AMOUNT for 2015
.00
Loss
Yes
No
Loss
44 Is this mainly – Mark (X) ONE box.
manufacturing?
d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No
§.#h¥¤
➜
Now continue with the mailing instructions on
page 28.
19
13197280
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 0607-0810 and 0607-0936,
U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810 and 0607-0936" as the subject. Please
DO NOT RETURN your questionnaire to this address.
Use the enclosed preaddressed envelope to return your
completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(X)IWW (10-06-2016)
28
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| File Type | application/pdf |
| File Modified | 2016-10-18 |
| File Created | 2016-10-06 |