ACS -1- (X)CTT The American Community Survey Content Test Question

Attachment L2 -- ACS-1(X)CTT, Content Test Test Questionnaire

DC

13056015
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

Start Here
Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it
back as soon as possible.

➜

Please print today’s date.
Month
Day
Year

➜

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

This form asks for information about the
people who are living or staying at the
address on the mailing label and about the
house, apartment, or mobile home located
at the address on the mailing label.

MI

First Name

Area Code + Number
If you need help or have questions
about completing this form, please call
1-888-595-1327. The telephone call is free.

—

➜

How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people

➜

Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.

Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-888-369-3615.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/

ACS-1(X)CTT

FORM
(06-09-2015) Draft 4 V2

§.&]0¤

OMB No. 0607-0936

13056023

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

Person 1

5

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Male

Month

Day

Year of birth

C

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)

Which categories describe Person 1? Mark all boxes that apply AND
print details in the spaces below.
White — Print details, for example, German, Irish, English, etc.

2

Opposite-sex unmarried partner

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

Female

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

Grandchild

Father or mother

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

4

MI

How is this person related to Person 1?
X

3

First Name

Opposite-sex husband/wife/spouse

Month

Day

Year of birth

5 Which categories describe Person 2? Mark all boxes that apply AND
print details in the spaces below.
White — Print details, for example, German, Irish, English, etc.

C

Hispanic, Latino, or Spanish origin — Print details, for example, Mexican
or Mexican American, Puerto Rican, Colombian, etc. C

Hispanic, Latino, or Spanish origin — Print details, for example, Mexican
or Mexican American, Puerto Rican, Colombian, etc. C

Black or African Am. — Print details, for example, African American,
Jamaican, Nigerian, etc. C

Black or African Am. — Print details, for example, African American,
Jamaican, Nigerian, etc. C

Asian — Print details, for example, Chinese, Asian Indian, Vietnamese, etc. C

Asian — Print details, for example, Chinese, Asian Indian, Vietnamese, etc. C

American Indian or Alaska Native — Print name(s) of enrolled or principal
tribe(s), for example, Navajo Nation, Mayan, Native Village of Barrow Inupiat
Traditional Government, etc. C

American Indian or Alaska Native — Print name(s) of enrolled or principal
tribe(s), for example, Navajo Nation, Mayan, Native Village of Barrow Inupiat
Traditional Government, etc. C

Middle Eastern or North African — Print details, for example, Lebanese,
Iranian, Egyptian, etc. C

Middle Eastern or North African — Print details, for example, Lebanese,
Iranian, Egyptian, etc. C

Native Hawaiian or Other Pacific Islander — Print details, for example,
Native Hawaiian, Chamorro, Fijian, etc. C

Native Hawaiian or Other Pacific Islander — Print details, for example,
Native Hawaiian, Chamorro, Fijian, etc. C

Some other race, ethnicity, or origin — Print details.

Some other race, ethnicity, or origin — Print details.

§.&]8¤

C

C

13056031

Person 3
1

1 What is Person 4’s name?

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

2

Person 4

First Name

MI

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

2 How is this person related to Person 1? Mark (X) ONE box.
Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or daughter-in-law

Same-sex husband/wife/spouse

Son-in-law or daughter-in-law

Same-sex unmarried partner

Other relative

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Brother or sister

Other nonrelative

Father or mother

3 What is Person 4’s sex? Mark (X) ONE box.

What is Person 3’s sex? Mark (X) ONE box.
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.
Age (in years)

5

MI

Grandchild

Male

4

First Name

Opposite-sex husband/wife/spouse

Father or mother

3

Last Name (Please print)

Month

Day

Year of birth

White — Print details, for example, German, Irish, English, etc.

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)

Which categories describe Person 3? Mark all boxes that apply AND
print details in the spaces below.
C

Female

Month

Day

Year of birth

5 Which categories describe Person 4? Mark all boxes that apply AND
print details in the spaces below.
White — Print details, for example, German, Irish, English, etc.

C

Hispanic, Latino, or Spanish origin — Print details, for example, Mexican
or Mexican American, Puerto Rican, Colombian, etc. C

Hispanic, Latino, or Spanish origin — Print details, for example, Mexican
or Mexican American, Puerto Rican, Colombian, etc. C

Black or African Am. — Print details, for example, African American,
Jamaican, Nigerian, etc. C

Black or African Am. — Print details, for example, African American,
Jamaican, Nigerian, etc. C

Asian — Print details, for example, Chinese, Asian Indian, Vietnamese, etc. C

Asian — Print details, for example, Chinese, Asian Indian, Vietnamese, etc. C

American Indian or Alaska Native — Print name(s) of enrolled or principal
tribe(s), for example, Navajo Nation, Mayan, Native Village of Barrow Inupiat
Traditional Government, etc. C

American Indian or Alaska Native — Print name(s) of enrolled or principal
tribe(s), for example, Navajo Nation, Mayan, Native Village of Barrow Inupiat
Traditional Government, etc. C

Middle Eastern or North African — Print details, for example, Lebanese,
Iranian, Egyptian, etc. C

Middle Eastern or North African — Print details, for example, Lebanese,
Iranian, Egyptian, etc. C

Native Hawaiian or Other Pacific Islander — Print details, for example,
Native Hawaiian, Chamorro, Fijian, etc. C

Native Hawaiian or Other Pacific Islander — Print details, for example,
Native Hawaiian, Chamorro, Fijian, etc. C

Some other race, ethnicity, or origin — Print details.

Some other race, ethnicity, or origin — Print details.

§.&]@¤

C

C

3

13056049

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

Opposite-sex husband/wife/spouse

Grandchild

Opposite-sex unmarried partner

Parent-in-law

Same-sex husband/wife/spouse

Son-in-law or daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Sex

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 sex? Mark (X) ONE box.
Male

4

MI

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

Father or mother

3

First Name

Female

Last Name (Please print)

First Name

MI

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

Month

Day

Year of birth
Sex

Male

Female

Age (in years)

Person 9
5

Which categories describe Person 5? Mark all boxes that apply AND
print details in the spaces below.
White — Print details, for example, German, Irish, English, etc.

Last Name (Please print)

First Name

MI

C

Hispanic, Latino, or Spanish origin — Print details, for example, Mexican
or Mexican American, Puerto Rican, Colombian, etc. C

Black or African Am. — Print details, for example, African American,
Jamaican, Nigerian, etc. C

Asian — Print details, for example, Chinese, Asian Indian, Vietnamese, etc. C

Sex

Male

Female

Age (in years)

Person 10
Last Name (Please print)

Sex

Male

First Name

Female

MI

Age (in years)

Person 11
American Indian or Alaska Native — Print name(s) of enrolled or principal
tribe(s), for example, Navajo Nation, Mayan, Native Village of Barrow Inupiat
Traditional Government, etc. C

Middle Eastern or North African — Print details, for example, Lebanese,
Iranian, Egyptian, etc. C

Last Name (Please print)

Sex

Male

First Name

Female

MI

Age (in years)

Person 12
Native Hawaiian or Other Pacific Islander — Print details, for example,
Native Hawaiian, Chamorro, Fijian, etc. C

Some other race, ethnicity, or origin — Print details.

Last Name (Please print)

C

Sex

4

§.&]R¤

First Name

Male

Female

Age (in years)

MI

13056056

Housing
➜

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

A

Answer questions 4 and 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

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?

A building with 3 or 4 apartments

None

A building with 5 to 9 apartments

$1 to $999

A building with 10 to 19 apartments

$1,000 to $2,499

A building with 20 to 49 apartments

$2,500 to $4,999

A building with 50 or more apartments

$5,000 to $9,999

Boat, RV, van, etc.

$10,000 or more

6 a. How many separate rooms are in this
2

About when was this building first built?
2000 or later – Specify year

1990 to 1999
1980 to 1989

Number of rooms

1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

3

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.

1970 to 1979

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

Year

home have –

Yes

No

a. hot and cold running water?
b. a bathtub or shower?

mobile home on?

1

7 Does this house, apartment, or mobile

c. a sink with a faucet?
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

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
a. Desktop or laptop
b. Smartphone
c. Tablet or other portable
wireless computer
d. Some other type of computer
Specify C

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
list if this house, apartment, or mobile home 11 Do you or any member of this household
have access to the Internet using a –
were for sale or rent. If this is an
efficiency/studio apartment, print "0".
Yes
No
a. Cellular data plan for a
Number of bedrooms
smartphone or other mobile
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 C

§.&]Y¤

5

13056064

Housing (continued)
12 How many automobiles, vans, and trucks
of one-ton capacity or less are kept at
home for use by members of this
household?

14 a. LAST MONTH, what was the cost
of electricity for this house,
apartment, or mobile home?
Last month’s cost – Dollars

$

.00

,

None

OR

1

No

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

Last month’s cost – Dollars

6 or more

$

.00

,

house, apartment, or mobile home?

Monthly amount – Dollars

Wood
Solar energy
Other fuel

c. IN THE PAST 12 MONTHS, what was
the cost of water and sewer for this
house, apartment, or mobile home? If
you have lived here less than 12 months,
estimate the cost.
Past 12 months’ cost – Dollars

$

.00

,

No fuel used

OR
Included in rent or condominium fee
No charge
d. IN THE PAST 12 MONTHS, what was the
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
home? If you have lived here less than 12
months, estimate the cost.
Past 12 months’ cost – Dollars

$

.00

,
OR

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

§.&]a¤

$

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

Electricity

Coal or coke

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

Included in rent or condominium fee

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

Fuel oil, kerosene, etc.

part of a condominium?

OR

13 Which FUEL is used MOST for heating this

6

any member of this household receive
benefits from the Food Stamp Program
or SNAP (the Supplemental Nutrition
Assistance Program)? Do NOT include
WIC, the School Lunch Program, or
assistance from food banks.
Yes

Included in rent or condominium fee

2

15 IN THE PAST 12 MONTHS, did you or

.00

,
OR
None

No

17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
Owned by you or someone in this
household with a mortgage or
loan? Include home equity loans.
Owned by you or someone in this
household free and clear (without a
mortgage or loan)?
Rented?
Occupied without payment of
rent? ➔ SKIP to C on the next page

13056072

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 28 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

§.&]i¤

7

13056080

Person 1

10 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
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

6

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

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?
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.)

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

7

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 9a

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

8

9

United States more than once, print latest year.

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)

Year

Doctorate degree (for example: PhD, EdD)

When did this person come to live in the
United States? If this person came to live in

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
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 15

No, different house in the United States or
Puerto Rico

Address (Number and street name)

11 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 10
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

§.&]q¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13056098

Person 1 (continued)

H

15 Is this person CURRENTLY covered by any of the

Answer question 18a – 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
18 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Do NOT include plans that cover only one type of
difficulty concentrating, remembering, or
service, such as dental, drug or vision plans.
making decisions?
Yes
No
a. Insurance through a current or
Yes
former employer or union (of this
person or another family member)
No
b. Medicare, for people 65 and older,
b. Does this person have serious difficulty
or people with certain disabilities
walking or climbing stairs?
c. Medicaid, Medical Assistance, or
any kind of state- or
Yes
government-assistance plan
for those with low income
No
d. Insurance purchased directly from
c. Does this person have difficulty dressing or
an insurance company or through a
bathing?
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
Yes
family member)
No
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
g. Indian Health Service
h. Other type of health coverage NOT
listed above – Specify C

I

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

19 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

G

Answer question 16a if this person is
covered by health insurance. Otherwise,
SKIP to question 17a.

pay a premium for this health insurance 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.
Yes

Yes
No

17 a. Is this person deaf or does he/she have
serious difficulty hearing?

24 Has this person given birth to any children in
the past 12 months?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Yes
No ➔ SKIP to question 26
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
1 or 2 years
3 or 4 years

No

5 or more years

26 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
Divorced

Never served in the military ➔ SKIP to
question 29a

Separated

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

Never married ➔ SKIP to J

Now on active duty

No ➔ SKIP to question 17a
b. Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the premium
for this plan?

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

Yes

20 What is this person’s marital status?
16 a. Does this person or another family member

J

21 In the PAST 12 MONTHS did this person get –
Yes

On active duty in the past, but not now

No

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

22 How many times has this person been married?

27 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

Yes

Two times

Vietnam era (August 1964 to April 1975)

No

Three or more times

February 1955 to July 1964

b. Is this person blind or does he/she have
In what year did this person last get married?
serious difficulty seeing even when wearing 23
Year
glasses?
Yes
No

§.&]¥¤

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

9

13056106

Person 1 (continued)

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

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

Car, truck, or van

Taxicab

Yes ➔ SKIP to question 37

Bus

Motorcycle

No

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

10 or 20 percent

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 39a

30 or 40 percent

Ferryboat

Other method

K

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

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

at a job (or business)?

No – Did not work (or retired)

32 How many people, including this person,

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.)

38 When did this person last work, even for a few

Person(s)

days?
Within the past 12 months

No ➔ SKIP to question 35a

1 to 5 years ago ➔ SKIP to M

33 LAST WEEK, what time did this person’s trip to

WEEK? If this person worked at more than one

work usually begin?

location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

a.m.
p.m.

34 How many minutes did it usually take this

L

Over 5 years ago or never worked ➔ SKIP to
question 42

39 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.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 40

Minutes

No

b. Name of city, town, or post office

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

No ➔ SKIP to question 38

usually rode to work in the car, truck, or van
LAST WEEK?

Yes

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

Yes

No, because of own temporary illness

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

30 At what location did this person work LAST

ACTIVELY looking for work?

37 LAST WEEK, could this person have started a

50 or 60 percent

Yes ➔ SKIP to question 30

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

36 During the LAST 4 WEEKS, has this person been

0 percent

70 percent or higher

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

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

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

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

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

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

No

Usual hours worked each WEEK

e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36

10

§.&^’¤

40 During the PAST 12 MONTHS, in the WEEKS

13056114

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 41a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.

41 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)

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

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)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.&^/¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

No

,

,

No

Yes ➔
No

,

,

No

No

$

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

43 What was this person’s total income during the

Loss

PAST 12 MONTHS? Add entries in questions 42a
to 42h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

No

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

$

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

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.

.00

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

Yes ➔

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

$

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?
42 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

$

None

$

,

,

TOTAL AMOUNT for past
12 months

.00
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 28 for mailing instructions.

11

13056122

Person 2

10 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
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

6

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

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?
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.)

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

7

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 9a

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

8

9

United States more than once, print latest year.

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)

Year

Doctorate degree (for example: PhD, EdD)

When did this person come to live in the
United States? If this person came to live in

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
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 15

No, different house in the United States or
Puerto Rico

Address (Number and street name)

11 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 10
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

§.&^7¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13056130

Person 2 (continued)

H

15 Is this person CURRENTLY covered by any of the

Answer question 18a – 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
18 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Do NOT include plans that cover only one type of
difficulty concentrating, remembering, or
service, such as dental, drug or vision plans.
making decisions?
Yes
No
a. Insurance through a current or
Yes
former employer or union (of this
person or another family member)
No
b. Medicare, for people 65 and older,
b. Does this person have serious difficulty
or people with certain disabilities
walking or climbing stairs?
c. Medicaid, Medical Assistance, or
any kind of state- or
Yes
government-assistance plan
for those with low income
No
d. Insurance purchased directly from
c. Does this person have difficulty dressing or
an insurance company or through a
bathing?
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
Yes
family member)
No
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
g. Indian Health Service
h. Other type of health coverage NOT
listed above – Specify C

I

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

19 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

G

Answer question 16a if this person is
covered by health insurance. Otherwise,
SKIP to question 17a.

pay a premium for this health insurance 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.
Yes

Yes
No

17 a. Is this person deaf or does he/she have
serious difficulty hearing?

24 Has this person given birth to any children in
the past 12 months?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Yes
No ➔ SKIP to question 26
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
1 or 2 years
3 or 4 years

No

5 or more years

26 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
Divorced

Never served in the military ➔ SKIP to
question 29a

Separated

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

Never married ➔ SKIP to J

Now on active duty

No ➔ SKIP to question 17a
b. Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the premium
for this plan?

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

Yes

20 What is this person’s marital status?
16 a. Does this person or another family member

J

21 In the PAST 12 MONTHS did this person get –
Yes

On active duty in the past, but not now

No

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

22 How many times has this person been married?

27 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

Yes

Two times

Vietnam era (August 1964 to April 1975)

No

Three or more times

February 1955 to July 1964

b. Is this person blind or does he/she have
In what year did this person last get married?
serious difficulty seeing even when wearing 23
Year
glasses?
Yes
No

§.&^?¤

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

13

13056148

Person 2 (continued)

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

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

Car, truck, or van

Taxicab

Yes ➔ SKIP to question 37

Bus

Motorcycle

No

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

10 or 20 percent

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 39a

30 or 40 percent

Ferryboat

Other method

K

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

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

at a job (or business)?

No – Did not work (or retired)

32 How many people, including this person,

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.)

38 When did this person last work, even for a few

Person(s)

days?
Within the past 12 months

No ➔ SKIP to question 35a

1 to 5 years ago ➔ SKIP to M

33 LAST WEEK, what time did this person’s trip to

WEEK? If this person worked at more than one

work usually begin?

location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

a.m.
p.m.

34 How many minutes did it usually take this

L

Over 5 years ago or never worked ➔ SKIP to
question 42

39 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.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 40

Minutes

No

b. Name of city, town, or post office

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

No ➔ SKIP to question 38

usually rode to work in the car, truck, or van
LAST WEEK?

Yes

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

Yes

No, because of own temporary illness

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

30 At what location did this person work LAST

ACTIVELY looking for work?

37 LAST WEEK, could this person have started a

50 or 60 percent

Yes ➔ SKIP to question 30

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

36 During the LAST 4 WEEKS, has this person been

0 percent

70 percent or higher

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

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

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

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

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

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

No

Usual hours worked each WEEK

e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36

14

§.&^Q¤

40 During the PAST 12 MONTHS, in the WEEKS

13056155

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 41a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.

41 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)

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

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)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.&^X¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

No

,

,

No

Yes ➔
No

,

,

No

No

$

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

43 What was this person’s total income during the

Loss

PAST 12 MONTHS? Add entries in questions 42a
to 42h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

No

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

$

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

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.

.00

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

Yes ➔

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

$

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?
42 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

$

None

$

,

,

TOTAL AMOUNT for past
12 months

.00
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 28 for mailing instructions.

15

13056163

Person 3

10 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
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

6

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

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?
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.)

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

7

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 9a

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

8

9

United States more than once, print latest year.

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)

Year

Doctorate degree (for example: PhD, EdD)

When did this person come to live in the
United States? If this person came to live in

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
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 15

No, different house in the United States or
Puerto Rico

Address (Number and street name)

11 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 10
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

§.&^‘¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13056171

Person 3 (continued)

H

15 Is this person CURRENTLY covered by any of the

Answer question 18a – 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
18 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Do NOT include plans that cover only one type of
difficulty concentrating, remembering, or
service, such as dental, drug or vision plans.
making decisions?
Yes
No
a. Insurance through a current or
Yes
former employer or union (of this
person or another family member)
No
b. Medicare, for people 65 and older,
b. Does this person have serious difficulty
or people with certain disabilities
walking or climbing stairs?
c. Medicaid, Medical Assistance, or
any kind of state- or
Yes
government-assistance plan
for those with low income
No
d. Insurance purchased directly from
c. Does this person have difficulty dressing or
an insurance company or through a
bathing?
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
Yes
family member)
No
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
g. Indian Health Service
h. Other type of health coverage NOT
listed above – Specify C

I

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 4 on page 20.

19 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

G

Answer question 16a if this person is
covered by health insurance. Otherwise,
SKIP to question 17a.

pay a premium for this health insurance 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.
Yes

Yes
No

17 a. Is this person deaf or does he/she have
serious difficulty hearing?

24 Has this person given birth to any children in
the past 12 months?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Yes
No ➔ SKIP to question 26
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
1 or 2 years
3 or 4 years

No

5 or more years

26 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
Divorced

Never served in the military ➔ SKIP to
question 29a

Separated

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

Never married ➔ SKIP to J

Now on active duty

No ➔ SKIP to question 17a
b. Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the premium
for this plan?

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

Yes

20 What is this person’s marital status?
16 a. Does this person or another family member

J

21 In the PAST 12 MONTHS did this person get –
Yes

On active duty in the past, but not now

No

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

22 How many times has this person been married?

27 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

Yes

Two times

Vietnam era (August 1964 to April 1975)

No

Three or more times

February 1955 to July 1964

b. Is this person blind or does he/she have
In what year did this person last get married?
serious difficulty seeing even when wearing 23
Year
glasses?
Yes
No

§.&^h¤

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

17

13056189

Person 3 (continued)

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

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

Car, truck, or van

Taxicab

Yes ➔ SKIP to question 37

Bus

Motorcycle

No

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

10 or 20 percent

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 39a

30 or 40 percent

Ferryboat

Other method

K

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

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

at a job (or business)?

No – Did not work (or retired)

32 How many people, including this person,

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.)

38 When did this person last work, even for a few

Person(s)

days?
Within the past 12 months

No ➔ SKIP to question 35a

1 to 5 years ago ➔ SKIP to M

33 LAST WEEK, what time did this person’s trip to

WEEK? If this person worked at more than one

work usually begin?

location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

a.m.
p.m.

34 How many minutes did it usually take this

L

Over 5 years ago or never worked ➔ SKIP to
question 42

39 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.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 40

Minutes

No

b. Name of city, town, or post office

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

No ➔ SKIP to question 38

usually rode to work in the car, truck, or van
LAST WEEK?

Yes

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

Yes

No, because of own temporary illness

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

30 At what location did this person work LAST

ACTIVELY looking for work?

37 LAST WEEK, could this person have started a

50 or 60 percent

Yes ➔ SKIP to question 30

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

36 During the LAST 4 WEEKS, has this person been

0 percent

70 percent or higher

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

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

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

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

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

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

No

Usual hours worked each WEEK

e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36

18

§.&^z¤

40 During the PAST 12 MONTHS, in the WEEKS

13056197

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 41a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.

41 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)

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

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)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.&^¿¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

No

,

,

No

Yes ➔
No

,

,

No

No

$

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

43 What was this person’s total income during the

Loss

PAST 12 MONTHS? Add entries in questions 42a
to 42h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

No

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

$

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

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.

.00

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

Yes ➔

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

$

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?
42 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

$

None

$

,

,

TOTAL AMOUNT for past
12 months

.00
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 28 for mailing instructions.

19

13056205

Person 4

10 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 4 from page 3,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

6

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

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?
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.)

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

7

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 9a

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

8

9

United States more than once, print latest year.

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)

Year

Doctorate degree (for example: PhD, EdD)

When did this person come to live in the
United States? If this person came to live in

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
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 15

No, different house in the United States or
Puerto Rico

Address (Number and street name)

11 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 10
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)

20

§.&_&¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13056213

Person 4 (continued)

H

15 Is this person CURRENTLY covered by any of the

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
18 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Do NOT include plans that cover only one type of
difficulty concentrating, remembering, or
service, such as dental, drug or vision plans.
making decisions?
Yes
No
a. Insurance through a current or
Yes
former employer or union (of this
person or another family member)
No
b. Medicare, for people 65 and older,
b. Does this person have serious difficulty
or people with certain disabilities
walking or climbing stairs?
c. Medicaid, Medical Assistance, or
any kind of state- or
Yes
government-assistance plan
for those with low income
No
d. Insurance purchased directly from
c. Does this person have difficulty dressing or
an insurance company or through a
bathing?
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
Yes
family member)
No
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
g. Indian Health Service
h. Other type of health coverage NOT
listed above – Specify C

I

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

19 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

G

Answer question 16a if this person is
covered by health insurance. Otherwise,
SKIP to question 17a.

pay a premium for this health insurance 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.
Yes

Yes
No

17 a. Is this person deaf or does he/she have
serious difficulty hearing?

24 Has this person given birth to any children in
the past 12 months?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Yes
No ➔ SKIP to question 26
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
1 or 2 years
3 or 4 years

No

5 or more years

26 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
Divorced

Never served in the military ➔ SKIP to
question 29a

Separated

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

Never married ➔ SKIP to J

Now on active duty

No ➔ SKIP to question 17a
b. Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the premium
for this plan?

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

Yes

20 What is this person’s marital status?
16 a. Does this person or another family member

J

21 In the PAST 12 MONTHS did this person get –
Yes

On active duty in the past, but not now

No

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

22 How many times has this person been married?

27 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

Yes

Two times

Vietnam era (August 1964 to April 1975)

No

Three or more times

February 1955 to July 1964

b. Is this person blind or does he/she have
In what year did this person last get married?
serious difficulty seeing even when wearing 23
Year
glasses?
Yes
No

§.&_.¤

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

21

13056221

Person 4 (continued)

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

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

Car, truck, or van

Taxicab

Yes ➔ SKIP to question 37

Bus

Motorcycle

No

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

10 or 20 percent

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 39a

30 or 40 percent

Ferryboat

Other method

K

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

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

at a job (or business)?

No – Did not work (or retired)

32 How many people, including this person,

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.)

38 When did this person last work, even for a few

Person(s)

days?
Within the past 12 months

No ➔ SKIP to question 35a

1 to 5 years ago ➔ SKIP to M

33 LAST WEEK, what time did this person’s trip to

WEEK? If this person worked at more than one

work usually begin?

location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

a.m.
p.m.

34 How many minutes did it usually take this

L

Over 5 years ago or never worked ➔ SKIP to
question 42

39 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.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 40

Minutes

No

b. Name of city, town, or post office

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

No ➔ SKIP to question 38

usually rode to work in the car, truck, or van
LAST WEEK?

Yes

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

Yes

No, because of own temporary illness

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

30 At what location did this person work LAST

ACTIVELY looking for work?

37 LAST WEEK, could this person have started a

50 or 60 percent

Yes ➔ SKIP to question 30

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

36 During the LAST 4 WEEKS, has this person been

0 percent

70 percent or higher

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

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

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

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

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

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

No

Usual hours worked each WEEK

e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36

22

§.&_6¤

40 During the PAST 12 MONTHS, in the WEEKS

13056239

Person 4 (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 41a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.

41 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)

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

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)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.&_H¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

No

,

,

No

Yes ➔
No

,

,

No

No

$

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

43 What was this person’s total income during the

Loss

PAST 12 MONTHS? Add entries in questions 42a
to 42h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

No

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

$

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

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.

.00

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

Yes ➔

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

$

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?
42 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

$

None

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Continue with the questions for Person 5 on
the next page. If no one is listed as Person 5 on
page 4, SKIP to page 28 for mailing instructions.

23

13056247

Person 5

10 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 5 from page 4,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12

First Name

MI

Nursery school
Kindergarten

6

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

Grade 1 through 11 – Specify
grade 1 – 11

Where was this person born?
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.)

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

7

Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 9a

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

8

9

United States more than once, print latest year.

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)

Year

Doctorate degree (for example: PhD, EdD)

When did this person come to live in the
United States? If this person came to live in

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

Very well
Well
Not well
Not at all

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

Person is under 1 year old ➔ SKIP to
question 15
Yes, this house ➔ SKIP to question 15
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 15

No, different house in the United States or
Puerto Rico

Address (Number and street name)

11 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 10
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)

24

§.&_P¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13056254

Person 5 (continued)

H

15 Is this person CURRENTLY covered by any of the

Answer question 18a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type
18 a. Because of a physical, mental, or emotional
of coverage in items a – h.
condition, does this person have serious
Do NOT include plans that cover only one type of
difficulty concentrating, remembering, or
service, such as dental, drug or vision plans.
making decisions?
Yes
No
a. Insurance through a current or
Yes
former employer or union (of this
person or another family member)
No
b. Medicare, for people 65 and older,
b. Does this person have serious difficulty
or people with certain disabilities
walking or climbing stairs?
c. Medicaid, Medical Assistance, or
any kind of state- or
Yes
government-assistance plan
for those with low income
No
d. Insurance purchased directly from
c. Does this person have difficulty dressing or
an insurance company or through a
bathing?
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
Yes
family member)
No
e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)
g. Indian Health Service
h. Other type of health coverage NOT
listed above – Specify C

I

Answer question 19 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

19 Because of a physical, mental, or emotional
condition, does this person have difficulty
doing errands alone such as visiting a doctor’s
office or shopping?

G

Answer question 16a if this person is
covered by health insurance. Otherwise,
SKIP to question 17a.

pay a premium for this health insurance 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.
Yes

Yes
No

17 a. Is this person deaf or does he/she have
serious difficulty hearing?

24 Has this person given birth to any children in
the past 12 months?
Yes
No

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

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 26

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Yes
No ➔ SKIP to question 26
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
1 or 2 years
3 or 4 years

No

5 or more years

26 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
Divorced

Never served in the military ➔ SKIP to
question 29a

Separated

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 28a

Never married ➔ SKIP to J

Now on active duty

No ➔ SKIP to question 17a
b. Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the premium
for this plan?

Answer question 24 if this person is
female and 15 – 50 years old. Otherwise,
SKIP to question 25a.

Yes

20 What is this person’s marital status?
16 a. Does this person or another family member

J

21 In the PAST 12 MONTHS did this person get –
Yes

On active duty in the past, but not now

No

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

22 How many times has this person been married?

27 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

Yes

Two times

Vietnam era (August 1964 to April 1975)

No

Three or more times

February 1955 to July 1964

b. Is this person blind or does he/she have
In what year did this person last get married?
serious difficulty seeing even when wearing 23
Year
glasses?
Yes
No

§.&_W¤

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

25

13056262

Person 5 (continued)

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

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

Car, truck, or van

Taxicab

Yes ➔ SKIP to question 37

Bus

Motorcycle

No

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

10 or 20 percent

Light rail, streetcar,
or trolley

Worked from
home ➔ SKIP
to question 39a

30 or 40 percent

Ferryboat

Other method

K

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

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

at a job (or business)?

No – Did not work (or retired)

32 How many people, including this person,

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.)

38 When did this person last work, even for a few

Person(s)

days?
Within the past 12 months

No ➔ SKIP to question 35a

1 to 5 years ago ➔ SKIP to M

33 LAST WEEK, what time did this person’s trip to

WEEK? If this person worked at more than one

work usually begin?

location, print where he or she worked most
last week.

Hour

Minute

:

a. Address (Number and street name)

a.m.
p.m.

34 How many minutes did it usually take this

L

Over 5 years ago or never worked ➔ SKIP to
question 42

39 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.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 40

Minutes

No

b. Name of city, town, or post office

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

No ➔ SKIP to question 38

usually rode to work in the car, truck, or van
LAST WEEK?

Yes

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

Yes

No, because of own temporary illness

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

30 At what location did this person work LAST

ACTIVELY looking for work?

37 LAST WEEK, could this person have started a

50 or 60 percent

Yes ➔ SKIP to question 30

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

36 During the LAST 4 WEEKS, has this person been

0 percent

70 percent or higher

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

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

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

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

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c

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

No

Usual hours worked each WEEK

e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
f. ZIP Code

Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36

26

§.&__¤

40 During the PAST 12 MONTHS, in the WEEKS

13056270

Person 5 (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 41a – f if this person
worked in the past 5 years. Otherwise,
SKIP to question 42.

41 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)

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

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)

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.&_g¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

No

,

,

No

Yes ➔
No

,

,

No

No

$

,

,

$

.00

,

TOTAL AMOUNT for past
12 months

43 What was this person’s total income during the

Loss

PAST 12 MONTHS? Add entries in questions 42a
to 42h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.
OR

No

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

$

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

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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.

.00

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

Yes ➔

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

$

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?
42 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

$

None

$

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Now continue with the mailing instructions
on page 28.

27

13056288

Mailing
Instructions
➜ Please make sure you have...

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

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

For Census Bureau Use
POP

EDIT

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0936, U.S. Census Bureau,
4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0936" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
preaddressed envelope to return your completed
questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(X)CTT (06-09-2015)

28

§.&_y¤