2 ACS Questionnaire From Q29 V1

13199104

Person 1 (continued)

32 How did this person usually get to work LAST
WEEK? Mark ONE box for the method of
transportation used for most of the distance.

29 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 30a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

K

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

Answer question 33 if you marked "Car,
truck, or van" in question 32. Otherwise,
SKIP to question 34.

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

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

job if offered one, or returned to work if
recalled?
Yes, could have gone to work

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

39 When did this person last work, even for a few
Within the past 12 months
1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

34 LAST WEEK, what time did this person’s trip to
work usually begin?

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

Hour

:

40 a. During the PAST 12 MONTHS (52 weeks), did

a.m.

this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

p.m.

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

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

Over 5 years ago or never worked ➔ SKIP to
question 43

Minute

a. Address (Number and street name)

Minutes

Yes ➔ SKIP to question 41
No
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

b. Name of city, town, or post office

L
c. Is the work location inside the limits of that
city or town?

No

days?

Person(s)

Yes

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

No, because of own temporary illness

at a job (or business)?
Yes ➔ SKIP to question 31

will be recalled to work within the next
6 months OR been given a date to return to
work?

38 LAST WEEK, could this person have started a

50 or 60 percent
70 percent or higher

36 c. Has this person been informed that he or she

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise,
SKIP to question 40a.

Weeks

Yes
No, outside the city/town limits
d. Name of county

e. Name of U.S. state or foreign country

f. ZIP Code

36 a. LAST WEEK, was this person on layoff from
a job?

41 During the PAST 12 MONTHS, in the WEEKS

Yes ➔ SKIP to question 36c

WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

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 39
No ➔ SKIP to question 37

18

§.4|%¤

FORM

ACS-1(X)ACOWP2V1 (4-23-2018) Draft 1

OMB No. 0607-0725

13199112

Person 1 (continued)

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

d. Was this mainly – Mark (X) ONE box.
manufacturing?

M

Answer questions 42a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 43.

wholesale trade?

Yes ➔

retail trade?

No

The next series of questions is about the type of
employment this person had last week.

Yes ➔

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level
plumber)

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

,

.00

,

TOTAL AMOUNT for past
12 months
d. Social Security or Railroad Retirement.

other (agriculture, construction, service,
government, etc.)?

42 DESCRIPTION OF EMPLOYMENT

$

No

$

Loss

.00

,

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
SELF-EMPLOYED OR OTHER

f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

Yes ➔
No

Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit
family business or farm for 15 hours or
more per week
PRIVATE SECTOR EMPLOYEE

Employee of a For-profit company or
organization, or of an individual
Employee of a Non-profit organization
(including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE

Local government employee (for
example: city or county school district)
State government employee
(including state colleges/universities)
Active duty U.S. Armed Forces or
Commissioned Corps
Federal government civilian employee
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

.00

,

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.
Yes ➔
No

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

Yes ➔
No

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

,

,

Yes ➔

.00

No

,

,

.00

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

$

$

44 What was this person’s total income during the

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

.00

,

TOTAL AMOUNT for past
12 months

No

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.

$

.00

,

g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or
other accounts specifically designed for retirement.
Do not include Social Security.

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

$

TOTAL AMOUNT for past
12 months

43 INCOME IN THE PAST 12 MONTHS

Yes ➔
c. What kind of business or industry was this?
Include the main activity, product, or service
provided at the location where employed. (For
example: elementary school, residential
construction)

$

None
Loss

$

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜ Continue with the questions for Person 2 on

the next page. If no one is listed as person 2 on
page 3, SKIP to page 28 for mailing instructions.

§.4|-¤

19

13199146

Person 2 (continued)

32 How did this person usually get to work LAST
WEEK? Mark ONE box for the method of
transportation used for most of the distance.

29 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 30a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

K

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

Answer question 33 if you marked "Car,
truck, or van" in question 32. Otherwise,
SKIP to question 34.

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

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

job if offered one, or returned to work if
recalled?
Yes, could have gone to work

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

39 When did this person last work, even for a few
Within the past 12 months
1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

34 LAST WEEK, what time did this person’s trip to
work usually begin?

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

Hour

:

a.m.
p.m.

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

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

Over 5 years ago or never worked ➔ SKIP to
question 43

Minute

a. Address (Number and street name)

Minutes

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.
Yes ➔ SKIP to question 41
No
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

b. Name of city, town, or post office

L
c. Is the work location inside the limits of that
city or town?

No

days?

Person(s)

Yes

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

No, because of own temporary illness

at a job (or business)?
Yes ➔ SKIP to question 31

will be recalled to work within the next
6 months OR been given a date to return to
work?

38 LAST WEEK, could this person have started a

50 or 60 percent
70 percent or higher

36 c. Has this person been informed that he or she

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise,
SKIP to question 40a.

Weeks

Yes
No, outside the city/town limits
d. Name of county

e. Name of U.S. state or foreign country

f. ZIP Code

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c

WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

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 39
No ➔ SKIP to question 37

20

§.4|O¤

41 During the PAST 12 MONTHS, in the WEEKS

13199153

Person 2 (continued)

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

d. Was this mainly – Mark (X) ONE box.
manufacturing?

M

Answer questions 42a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 43.

Yes ➔

wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

,

.00

,

TOTAL AMOUNT for past
12 months

Loss

d. Social Security or Railroad Retirement.
Yes ➔

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level
plumber)

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

$

No

No

$

.00

,

TOTAL AMOUNT for past
12 months

e. Supplemental Security Income (SSI).
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
SELF-EMPLOYED OR OTHER

f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

Yes ➔
No

Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit
family business or farm for 15 hours or
more per week
PRIVATE SECTOR EMPLOYEE

Employee of a For-profit company or
organization, or of an individual
E,ployee of a Non-profit organization
(including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE

Local government employee (for
example: city or county school district)
State government employee
(including state colleges/universities)
Active duty U.S. Armed Forces or
Commissioned Corps
Federal government civilian employee
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

TOTAL AMOUNT for past
12 months

Yes ➔
No

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

Yes ➔
No

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

,

,

Yes ➔

.00

No

,

.00

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

,

$

44 What was this person’s total income during the

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

$

.00

,

TOTAL AMOUNT for past
12 months

No

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.

$

.00

,

g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or
other accounts specifically designed for retirement.
Do not include Social Security.

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

$

TOTAL AMOUNT for past
12 months

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

§.4|V¤

.00

,

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

Yes ➔
c. What kind of business or industry was this?
Include the main activity, product, or service
provided at the location where employed. (For
example: elementary school, residential
construction)

$

None
Loss

➜

$

,

,

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 28 for mailing instructions.

21

13199187

Person 3 (continued)

32 How did this person usually get to work LAST
WEEK? Mark ONE box for the method of
transportation used for most of the distance.

29 a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ... , 100%)
No ➔ SKIP to question 30a
b. What is this person’s service-connected
disability rating?
0 percent
10 or 20 percent
30 or 40 percent

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 40a

Ferryboat

Other method

K

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

Answer question 33 if you marked "Car,
truck, or van" in question 32. Otherwise,
SKIP to question 34.

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

No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

job if offered one, or returned to work if
recalled?
Yes, could have gone to work

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

39 When did this person last work, even for a few
Within the past 12 months
1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

34 LAST WEEK, what time did this person’s trip to
work usually begin?

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

Hour

:

a.m.
p.m.

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

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

Over 5 years ago or never worked ➔ SKIP to
question 43

Minute

a. Address (Number and street name)

Minutes

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.
Yes ➔ SKIP to question 41
No
b. During the PAST 12 MONTHS (52 weeks), how
many WEEKS did this person work? Include
paid time off and include weeks when the
person only worked for a few hours.

b. Name of city, town, or post office

L
c. Is the work location inside the limits of that
city or town?

No

days?

Person(s)

Yes

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

No, because of own temporary illness

at a job (or business)?
Yes ➔ SKIP to question 31

will be recalled to work within the next
6 months OR been given a date to return to
work?

38 LAST WEEK, could this person have started a

50 or 60 percent
70 percent or higher

36 c. Has this person been informed that he or she

Answer questions 36 – 39 if this person
did NOT work last week. Otherwise,
SKIP to question 40a.

Weeks

Yes
No, outside the city/town limits
d. Name of county

e. Name of U.S. state or foreign country

f. ZIP Code

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c

WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

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 39
No ➔ SKIP to question 37

22

§.4|x¤

41 During the PAST 12 MONTHS, in the WEEKS

13199195

Person 3 (continued)

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

d. Was this mainly – Mark (X) ONE box.
manufacturing?

M

Answer questions 42a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 43.

Yes ➔

retail trade?

No

other (agriculture, construction, service,
government, etc.)?

42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.

Employee of a For-profit company or
organization, or of an individual
E,ployee of a Non-profit organization
(including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE

Local government employee (for
example: city or county school district)
State government employee
(including state colleges/universities)
Active duty U.S. Armed Forces or
Commissioned Corps
Federal government civilian employee
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

No

Loss

$

.00

,

TOTAL AMOUNT for past
12 months

f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

f. Any public assistance or welfare payments
from the state or local welfare office.
Yes ➔
No
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

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

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.

No

,

.00

No

$

,

.00

TOTAL AMOUNT for past
12 months

.00

,

TOTAL AMOUNT for past
12 months

PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

,

$

44 What was this person’s total income during the

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

.00

,

TOTAL AMOUNT for past
12 months

No

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.

,

.00

,

g. Retirement income, pensions, survivor or
disability income. Include income from a previous
employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or
other accounts specifically designed for retirement.
Do not include Social Security.

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

$

$

TOTAL AMOUNT for past
12 months

43 INCOME IN THE PAST 12 MONTHS

Yes ➔

§.4|¢¤

.00

,

e. Supplemental Security Income (SSI).

Yes ➔
c. What kind of business or industry was this?
Include the main activity, product, or service
provided at the location where employed. (For
example: elementary school, residential
construction)

,

TOTAL AMOUNT for past
12 months

Yes ➔

Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit
family business or farm for 15 hours or
more per week
PRIVATE SECTOR EMPLOYEE

$

d. Social Security or Railroad Retirement.

e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level
plumber)

If this person had more than one job, describe the one
at which the most hours were worked. If this person
did not work last week, describe the most recent
employment in the past five years.

SELF-EMPLOYED OR OTHER

wholesale trade?

None
Loss

$

,

,

TOTAL AMOUNT for past
12 months

➜ Please stop here.

.00
Loss

Thank you.

23