Form 1 Modified ACS Paper Form

13199013

DC

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

Attachment E: The American Community Survey,
paper survey form ACS-1(X)hp

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.

First Name

MI

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 website at:
http://www.census.gov/acs

ACS-1(X)hp

FORM
(12-19-2018)

§.4{.¤

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

13199021

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

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this survey, Hispanic origins are not races.

5

6

Is Person 1 of Hispanic, Latino, or Spanish origin?

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

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. 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

Grandchild

Male

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)

Father or mother

Opposite-sex unmarried partner

3 What is Person 2’s sex? Mark (X) ONE box.

What is Person 1’s sex? Mark (X) ONE box.
Male

Opposite-sex husband/wife/spouse

§.4{6¤

Some other race – Print race. C

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

13199039

Person 3
1

1 What is Person 4’s name?

What is Person 3’s name?
Last Name (Please print)

2

3

First Name

MI

How is this person related to Person 1? Mark (X) ONE box.

MI

2 How is this person related to Person 1? Mark (X) ONE box.

Father or mother

Opposite-sex husband/wife/spouse

Father or mother

Grandchild

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Brother or sister

Other nonrelative

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

First Name

Opposite-sex unmarried partner

Age (in years)

5

Last Name (Please print)

Opposite-sex husband/wife/spouse

Male

4

Person 4

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

§.4{H¤

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

Some other race – Print race. C

3

13199047

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.

3

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

What is Person 5’s sex? Mark (X) ONE box.
Male

4

Female

Male

Female

Age (in years)

Person 7
Last Name (Please print)

Sex

Male

First Name

Female

MI

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)

Sex

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

§.4{P¤

MI

Male

Female

Age (in years)

MI

13199054

Housing
➜

Please answer the following
questions about the house,
apartment, or mobile home at the
address on the mailing label.

A

Answer questions 4 – 5 if this is a HOUSE
OR A MOBILE HOME; otherwise, SKIP to
question 6a.

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

2

4 How many acres is this house or
Less than 1 acre ➔ SKIP to question 6a
1 to 9.9 acres
10 or more acres

5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?

d. a stove or range?
e. a refrigerator?

8 Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
Include calls using cell phones, land lines, or
other phone devices.
Yes
No

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. Desktop or laptop

A building with 50 or more apartments

$5,000 to $9,999

Boat, RV, van, etc.

$10,000 or more

b. Smartphone
c. Tablet or other portable
wireless computer
d. Some other type of computer
Specify

1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

When did PERSON 1 (listed on page 2)
move into this house, apartment, or
mobile home?
Month

Year

No

c. a sink with a faucet?

None

About when was this building first built?

Yes

a. hot and cold running water?

A building with 3 or 4 apartments

2000 or later – Specify year

3

home have –

b. a bathtub or shower?
mobile home on?

1

7 Does this house, apartment, or mobile

9 At this house, apartment, or mobile home –
do you or any member of this household
own or use any of the following types of
computers?
Yes
No

6 a. How many separate rooms are in this
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.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms

10 At this house, apartment, or mobile home –
do you or any member of this household
have access to the Internet?
Yes, by paying a cell phone company or
Internet service provider
Yes, without paying a cell phone company
or Internet service provider ➔ SKIP to
question 12
No access to the Internet at this house,
apartment, or mobile home ➔ SKIP to
question 12

b. How many of these rooms are bedrooms?
Count as bedrooms those rooms you would 11 Do you or any member of this household
list if this house, apartment, or mobile home
have access to the Internet using a –
were for sale or rent. If this is an
Yes
No
efficiency/studio apartment, print "0".
a. cellular data plan for a
smartphone or other mobile
Number of bedrooms
device?
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service

§.4{W¤

5

13199062

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

15 IN THE PAST 12 MONTHS, did you or
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.

OR

1

Yes
No

Included in rent or condominium fee

2

No charge or electricity not used

16 Is this house, apartment, or mobile home

3
b. LAST MONTH, what was the cost
of gas for this house, apartment,
or mobile home?

4
5

part of a condominium or homeowner's
association?

Yes ➔ What is the required monthly
condominium fee or
homeowner's association fee?
For renters, answer only if you
pay the fee in addition to your
rent; otherwise, mark the
"None" box.

Last month’s cost – Dollars

6 or more

$

.00

,
OR

13 Which FUEL is used MOST for heating this
house, apartment, or mobile home?

Included in rent or condominium fee

Gas: from underground pipes serving the
neighborhood
Gas: bottled, tank, or LP

Monthly amount – Dollars

Included in electricity payment
entered above
No charge or gas not used

$

Electricity
Fuel oil, kerosene, etc.
Coal or coke
Wood
Solar energy
Other fuel

.00

,
OR

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

None
No

17 Is this house, apartment, or mobile home –
Mark (X) ONE box.

$

.00

,

Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.

OR

No fuel used

Included in rent or condominium fee

Owned by you or someone in this
household free and clear (without a
mortgage or loan)?

No charge

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.

Occupied without payment of
rent?

Past 12 months’ cost – Dollars

$

.00

,
OR

Included in rent or condominium fee
No charge or these fuels not used

6

§.4{_¤

➜

Answer questions about PERSON 1 on
page 8.

13199070

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?

18 a. What is the monthly rent for this
house, apartment, or mobile home?

Yes, mortgage, deed of trust, or similar
debt
Yes, contract to purchase

Yes, home equity loan

No ➔ SKIP to question 23a

Yes, second mortgage and home
equity loan
No ➔ SKIP to D

Yes, second mortgage

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?

.00

,

20 What are the annual real estate taxes on
THIS property?
Annual amount – Dollars

$

,

Monthly amount – Dollars

.00

$

.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?

,

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

Amount – Dollars

,

,
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.

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 20 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

§.4{g¤

7

13199088

Person 1

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 30
Yes, this house ➔ SKIP to question 30
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 30

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

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)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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)

8

§.4{y¤

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13199096

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

c. Does this person have difficulty dressing or
bathing?
Yes

g. Indian Health Service

No

h. Any other type of health insurance
or health coverage plan – Specify

Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.

17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

I

condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

serious difficulty hearing?
Yes

c. How long has this grandparent been
responsible for these grandchildren?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

Less than 6 months
6 to 11 months

5 or more years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty

22 In the PAST 12 MONTHS, did this person get –
Yes

No

a. Married?
b. Widowed?
c. Divorced?

23 How many times has this person been married?

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

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?

3 or 4 years

21 What is this person’s marital status?

No

Yes

grandchildren under the age of 18 living in
this house or apartment?

No

Separated

18 a. Is this person deaf or does he/she have

26 a. Does this person have any of his/her own

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

Yes

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in 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)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

24 In what year did this person last get married?
Year

On active duty in the past, but not now

Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

§.4{£¤

9

13199104

Person 1 (continued)

32 How did this person usually get to work LAST
WEEK? Mark (X) 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 Person 2

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?

34 LAST WEEK, what time did this person’s trip to
work usually begin?
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, describe the
location using a building name, a landmark, or
the nearest street or intersection.

Minutes

b. City, town, or post office

➜

Continue with the questions for Person 2 on
page 12. If no one is listed as Person 2 on page
2, SKIP to page 20 for mailing instructions.

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

10

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

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

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.
Weeks

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

Yes, inside the city or town limits

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

No, outside the city or town limits

No ➔ SKIP to question 37

§.4|%¤

No ➔ SKIP to question 39

Yes ➔ SKIP to question 36c

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

f. Is the work location inside the limits of the
city or town?

Yes

Minute

a. Address (Number and street name)

e. County

ACTIVELY looking for work?

1 to 5 years ago ➔ SKIP to M

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

d. ZIP Code

37 During the LAST 4 WEEKS, has this person been

Within the past 12 months

No ➔ SKIP to Person 2

c. U.S. state or foreign country

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

13199112

Person 1 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
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

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Yes ➔
No

$

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

$

.00

,

TOTAL AMOUNT for past
12 months

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.
Yes ➔
No

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city or
If net income was a loss, mark the "Loss" box to
county school district)
the right of the dollar amount.
State government (including state
colleges/universities)
For income received jointly, report the appropriate
Active duty U.S. Armed Forces or
share for each person – or, if that’s not possible,
Commissioned Corps
report the whole amount for only one person and
mark the "No" box for the other person.
Federal government civilian employee
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

.00

,

e. Supplemental Security Income (SSI).

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

$

$

.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.

.00

TOTAL AMOUNT for past
12 months

Yes ➔

$

.00

,

No

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
b. Self-employment income from own nonfarm
12 months
businesses or farm businesses, including
proprietorships and partnerships. Report
44 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
Yes ➔ $
enter the amount and mark (X) the "Loss" box next to
.00
,
,
the dollar amount.
No
Loss
TOTAL AMOUNT for past
12 months
OR $
.00

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

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

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

§.4|-¤

,

Yes ➔
No

$

,

,

None

,

TOTAL AMOUNT for past
12 months

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
2, SKIP to page 20 for mailing instructions.

11

13199120

Person 2

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 30
Yes, this house ➔ SKIP to question 30
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 30

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

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)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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)

12

§.4|5¤

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13199138

Person 2 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

c. Does this person have difficulty dressing or
bathing?
Yes

g. Indian Health Service

No

h. Any other type of health insurance
or health coverage plan – Specify

Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.

17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

I

condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

serious difficulty hearing?
Yes

c. How long has this grandparent been
responsible for these grandchildren?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

Less than 6 months
6 to 11 months

5 or more years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty

22 In the PAST 12 MONTHS, did this person get –
Yes

No

a. Married?
b. Widowed?
c. Divorced?

23 How many times has this person been married?

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

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?

3 or 4 years

21 What is this person’s marital status?

No

Yes

grandchildren under the age of 18 living in
this house or apartment?

No

Separated

18 a. Is this person deaf or does he/she have

26 a. Does this person have any of his/her own

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

Yes

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in 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)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

24 In what year did this person last get married?
Year

On active duty in the past, but not now

Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

§.4|G¤

13

13199146

Person 2 (continued)

32 How did this person usually get to work LAST
WEEK? Mark (X) 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 Person 3

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?

34 LAST WEEK, what time did this person’s trip to
work usually begin?
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, describe the
location using a building name, a landmark, or
the nearest street or intersection.

Minutes

➜

Continue with the questions for Person 3 on
page 16. If no one is listed as Person 3 on page
3, SKIP to page 20 for mailing instructions.

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

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

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

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

Weeks

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

Yes, inside the city or town limits

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

No, outside the city or town limits

No ➔ SKIP to question 37

§.4|O¤

job if offered one, or returned to work if
recalled?

Yes ➔ SKIP to question 36c

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

14

No ➔ SKIP to question 39

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. City, town, or post office

f. Is the work location inside the limits of the
city or town?

Yes

Minute

a. Address (Number and street name)

e. County

ACTIVELY looking for work?

1 to 5 years ago ➔ SKIP to M

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

d. ZIP Code

37 During the LAST 4 WEEKS, has this person been

Within the past 12 months

No ➔ SKIP to Person 3

c. U.S. state or foreign country

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

13199153

Person 2 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
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

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Yes ➔
No

$

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

$

.00

,

TOTAL AMOUNT for past
12 months

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.
Yes ➔
No

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city or
If net income was a loss, mark the "Loss" box to
county school district)
the right of the dollar amount.
State government (including state
colleges/universities)
For income received jointly, report the appropriate
Active duty U.S. Armed Forces or
share for each person – or, if that’s not possible,
Commissioned Corps
report the whole amount for only one person and
mark the "No" box for the other person.
Federal government civilian employee
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

.00

,

e. Supplemental Security Income (SSI).

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

$

$

.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.

.00

TOTAL AMOUNT for past
12 months

Yes ➔

$

.00

,

No

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
b. Self-employment income from own nonfarm
12 months
businesses or farm businesses, including
proprietorships and partnerships. Report
44 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
Yes ➔ $
enter the amount and mark (X) the "Loss" box next to
.00
,
,
the dollar amount.
No
Loss
TOTAL AMOUNT for past
12 months
OR $
.00

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

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

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

§.4|V¤

,

Yes ➔
No

$

,

,

None

,

TOTAL AMOUNT for past
12 months

Loss

.00

TOTAL AMOUNT for past
12 months

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 20 for mailing instructions.

15

13199161

Person 3

11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.

➜

If currently enrolled, mark the previous grade or
highest degree received.

Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

14 a. Does this person speak a language other than
English at home?
Yes
No ➔ SKIP to question 15a
b. What is this language?

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 30
Yes, this house ➔ SKIP to question 30
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 30

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

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)

Name of city, town, or post office

Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12

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)

16

§.4|^¤

Name of U.S. county or
municipio in Puerto Rico

Name of U.S. state or
Puerto Rico

ZIP Code

13199179

Person 3 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
19 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Yes No
difficulty concentrating, remembering, or
a. Insurance through a current or
former employer or union (of this
making decisions?
person or another family member)
Yes
b. Insurance purchased directly from
an insurance company (by this
No
person or another family member)
b. Does this person have serious difficulty
c. Medicare, for people 65 and older,
walking or climbing stairs?
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability

c. Does this person have difficulty dressing or
bathing?
Yes

g. Indian Health Service

No

h. Any other type of health insurance
or health coverage plan – Specify

Answer question 17a if this person is
covered by health insurance. Otherwise,
SKIP to question 18a.

17 a. Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

I

condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

serious difficulty hearing?
Yes

c. How long has this grandparent been
responsible for these grandchildren?
If the grandparent is financially responsible for
more than one grandchild, answer the question
for the grandchild for whom the grandparent has
been responsible for the longest period of time.

Less than 6 months
6 to 11 months

5 or more years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
Now on active duty

22 In the PAST 12 MONTHS, did this person get –
Yes

No

a. Married?
b. Widowed?
c. Divorced?

23 How many times has this person been married?

b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?

No

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?

3 or 4 years

21 What is this person’s marital status?

No

Yes

grandchildren under the age of 18 living in
this house or apartment?

No

Separated

18 a. Is this person deaf or does he/she have

26 a. Does this person have any of his/her own

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

Yes

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

Answer question 25 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 26a.

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in 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)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

24 In what year did this person last get married?
Year

On active duty in the past, but not now

Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

§.4|p¤

17

13199187

Person 3 (continued)

32 How did this person usually get to work LAST
WEEK? Mark (X) 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 Page 20

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?

34 LAST WEEK, what time did this person’s trip to
work usually begin?
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, describe the
location using a building name, a landmark, or
the nearest street or intersection.

Minutes

➜

SKIP to page 20 for mailing instructions.

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

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

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

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

Weeks

41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?

No

Usual hours worked each WEEK

Yes, inside the city or town limits

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39

No, outside the city or town limits

No ➔ SKIP to question 37

§.4|x¤

job if offered one, or returned to work if
recalled?

Yes ➔ SKIP to question 36c

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?

18

No ➔ SKIP to question 39

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. City, town, or post office

f. Is the work location inside the limits of the
city or town?

Yes

Minute

a. Address (Number and street name)

e. County

ACTIVELY looking for work?

1 to 5 years ago ➔ SKIP to M

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

d. ZIP Code

37 During the LAST 4 WEEKS, has this person been

Within the past 12 months

No ➔ SKIP to page 20

c. U.S. state or foreign country

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

13199195

Person 3 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
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

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

Yes ➔
No

$

No

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

$

.00

,

TOTAL AMOUNT for past
12 months

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.
Yes ➔
No

a. Wages, salary, commissions, bonuses,
or tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Yes ➔

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city or
If net income was a loss, mark the "Loss" box to
county school district)
the right of the dollar amount.
State government (including state
colleges/universities)
For income received jointly, report the appropriate
Active duty U.S. Armed Forces or
share for each person – or, if that’s not possible,
Commissioned Corps
report the whole amount for only one person and
mark the "No" box for the other person.
Federal government civilian employee
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

.00

,

e. Supplemental Security Income (SSI).

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

$

$

.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.

.00

TOTAL AMOUNT for past
12 months

Yes ➔

$

.00

,

No

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
b. Self-employment income from own nonfarm
12 months
businesses or farm businesses, including
proprietorships and partnerships. Report
44 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 43a
to 43h; subtract any losses. If net income was a loss,
Yes ➔ $
enter the amount and mark (X) the "Loss" box next to
.00
,
,
the dollar amount.
No
Loss
TOTAL AMOUNT for past
12 months
OR $
.00

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

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

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

§.4|¢¤

,

Yes ➔
No

$

,

,

None

,

TOTAL AMOUNT for past
12 months

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

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 20 for mailing instructions.

19

13199286

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(2019) (08-02-2018)

20

§.4}w¤