ACS-1(2019)PR Puerto Rico Community Survey-1 (English)

13179015

DC

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

THE

Puerto Rico Community Survey

Please complete this form and return
it as soon as possible after receiving
it in the mail.
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.

Start Here
➜

Please print today’s date.
Month

➜

Day

Year

Please print the name and telephone number of the person who is
filling out this form. We will only contact you if needed for official
Census Bureau business.
Last Name

MI

First Name

Area Code + Number

—
If you need help or have questions
about completing this form, please call
1-800-717-7381. 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 1-800-786-9448. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-800-814-8385.
For more information about the Puerto Rico
Community Survey, visit our web site at:
http://www.census.gov/acs/

ACS-1(2019)PR

FORM
(02-02-2018) Draft 8

§.2{0¤

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

13179023

Person 1

Person 2
1 What is Person 2’s name?

(Person 1 is the person living or staying here in whose name this house
or apartment is owned, being bought, or rented. If there is no such
person, start with the name of any adult living or staying here.)

Last Name (Please print)

First Name

MI

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

1

What is Person 1’s name?
Last Name (Please print)

2

First Name

MI

How is this person related to Person 1?
X

3

Person 1

4

Female

Month

Day

Year of birth

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

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Female

4 What is Person 2’s age and what is Person 2’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Day

Year of birth

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

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

No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

6 What is Person 2’s race? Mark (X) one or more boxes.

What is Person 1’s race? Mark (X) one or more boxes.
White

White

Black or African Am.

Black or African Am.

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Some other race – Print race. C

2

Parent-in-law

Same-sex unmarried partner

5 Is Person 2 of Hispanic, Latino, or Spanish origin?

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

6

Same-sex husband/wife/spouse

Age (in years)

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

Grandchild

Male

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

Father or mother

Opposite-sex unmarried partner

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

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

Opposite-sex husband/wife/spouse

Some other race – Print race. C

§.2{8¤

ACS-1 PR KFI, Page 2, Base (Black)

ACS-1 PR KFI, Page 2, Pantone 129 (20 and 40%)

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

13179031

Person 3
1

1 What is Person 4’s name?

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

2

3

First Name

MI

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

MI

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

Father or mother

Opposite-sex husband/wife/spouse

Father or mother

Grandchild

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Brother or sister

Other nonrelative

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

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

Male

What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month

Day

Year of birth

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

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

6

First Name

Opposite-sex unmarried partner

Age (in years)

5

Last Name (Please print)

Opposite-sex husband/wife/spouse

Male

4

Person 4

Is Person 3 of Hispanic, Latino, or Spanish origin?

Female

4 What is Person 4’s age and what is Person 4’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth

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

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

5 Is Person 4 of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican Am., Chicano

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Puerto Rican

Yes, Cuban

Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

What is Person 3’s race? Mark (X) one or more boxes.

6 What is Person 4’s race? Mark (X) one or more boxes.

White

White

Black or African Am.

Black or African Am.

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian

Japanese

Native Hawaiian

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Filipino

Vietnamese

Samoan

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

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

Some other race – Print race. C

§.2{@¤

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

Some other race – Print race. C

3

13179049

Person 5
1

➜

What is Person 5’s name?
Last Name (Please print)

First Name

MI

If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.

Person 6
Last Name (Please print)

2

First Name

MI

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

3

Opposite-sex husband/wife/spouse

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

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

4

Female

Male

Female

Age (in years)

Person 7
Last Name (Please print)

Sex

Male

First Name

Female

MI

Age (in years)

Person 8

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

Sex

Month

Day

Last Name (Please print)

First Name

MI

Year of birth

Sex

Male

Female

Age (in years)

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

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

5

Is Person 5 of Hispanic, Latino, or Spanish origin?

Person 9
Last Name (Please print)

First Name

MI

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Sex

Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C

Male

Female

Person 10
Last Name (Please print)

6

Age (in years)

First Name

MI

What is Person 5’s race? Mark (X) one or more boxes.
White
Sex

Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Male

Female

Person 11
Last Name (Please print)

Asian Indian

Japanese

Native Hawaiian

Chinese

Korean

Guamanian or Chamorro

Filipino

Vietnamese

Samoan

Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C

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

Age (in years)

Sex

Male

First Name

Female

Age (in years)

Person 12
Last Name (Please print)

First Name

Some other race – Print race. C
Sex

4

§.2{R¤

MI

Male

Female

Age (in years)

MI

13179056

Housing
➜

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

A

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

Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments
A building with 3 or 4 apartments
A building with 5 to 9 apartments
A building with 10 to 19 apartments
A building with 20 to 49 apartments
A building with 50 or more apartments
Boat, RV, van, etc.

2

4 How many cuerdas is this house or

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

3

Less than 1 cuerda ➔ SKIP to question 6a
1 to 9.9 cuerdas
10 or more cuerdas

5 IN THE PAST 12 MONTHS, what
were the actual sales of all agricultural
products from this property?
None
$1 to $999
$1,000 to $2,499
$2,500 to $4,999
$5,000 to $9,999
$10,000 or more

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

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

Year

home have –

Yes

No

a. running water?
b. a water heater?

mobile home on?

1

7 Does this house, apartment, or mobile

c. a bathtub or shower?
d. a sink with a faucet?
e. a stove or range?
f. 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
computer?
Yes
No
a. Desktop or laptop
b. Smartphone
c. Tablet or other portable
wireless computer
d. Some other type of computer
Specify

6 a. How many separate rooms are in this
house, apartment, or mobile home?
Rooms must be separated by built-in
archways or walls that extend out at least
6 inches and go from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements.
Number of rooms

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

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

§.2{Y¤

5

13179064

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

any member of this household receive
benefits from the Nutritional Assistance
Program? Do NOT include WIC, the
School Lunch Program, or assistance
from food banks.
Yes
No

1

Included in rent or condominium fee

2

No charge or electricity not used

16 Is this house, apartment, or mobile home
part of a condominium?

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

4
5
6 or more

Last month’s cost – Dollars

$

.00

,

13 Which FUEL is used MOST for heating this

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

Electricity

Coal or coke
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

$

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

,

.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?

Included in rent or condominium fee

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

§.2{a¤

Monthly amount – Dollars

Included in rent or condominium fee

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

Fuel oil, kerosene, etc.

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.

OR

house, apartment, or mobile home?

6

15 IN THE PAST 12 MONTHS, did you or

Occupied without payment of
rent? ➔ SKIP to C on the next page

13179072

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?

b. How much is the regular monthly
mortgage payment on THIS property?
Include payment only on FIRST mortgage
or contract to purchase.
Monthly amount – Dollars

$

Yes

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

.00

,

$

No
OR

C

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 .

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

$

,

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

$

.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?

,

d. Does the regular monthly mortgage
payment include payments for fire,
hazard, or flood insurance on THIS
property?

personal property taxes, site rent,
registration fees, and license fees on
THIS mobile home and its site?
Exclude real estate taxes.
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

§.2{i¤

7

13179080

Person 1

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?

GED or alternative credential

Yes, born in Puerto Rico ➔ SKIP to question 10a

COLLEGE OR SOME COLLEGE

Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree

Bachelor’s degree (for example: BA, BS)
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)

No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year

10 a. At any time IN THE LAST 3 MONTHS, has this

Doctorate degree (for example: PhD, EdD)

F

person attended school or college? Include

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

No, has not attended in the last 3
months ➔ SKIP to question 11

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Associate’s degree (for example: AA, AS)

AFTER BACHELOR’S DEGREE

9

For example: Korean, Italian, Spanish, Vietnamese

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

15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.

No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?

12 This question focuses on this person’s

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

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)

Address
Development or condominium name
Number and street name

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

§.2{q¤

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

Enter Puerto Rico or
name of U.S. state

ZIP Code

13179098

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

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

g. Indian Health Service

No

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

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

there a premium for this plan? A premium
17 a. Is
is a fixed amount of money paid on a regular

I

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

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

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

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

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

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

No

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

23 How many times has this person been married?

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

No

c. How long has this grandparent been
responsible for these grandchildren?

5 or more years

21 What is this person’s marital status?

No

Yes

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

3 or 4 years

Separated

Yes

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

No

No ➔ SKIP to question 18a

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

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

1 or 2 years

Divorced

No

No

Yes

Yes

Yes

Yes

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

basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.

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

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

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

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

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

On active duty in the past, but not now

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

§.2{¥¤

9

13179106

Person 1 (continued)

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

29 a. Does this person have a VA service-connected
disability rating?

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

0 percent
10 or 20 percent

Carro público

30 or 40 percent

Ferryboat

Worked from
home ➔ SKIP
to question 40a

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

K

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

at a job (or business)?

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

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

Person(s)

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

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

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

days?

No ➔ SKIP to question 36a

Within the past 12 months

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

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

Hour

a. Address
Development or condominium name
Number and street name

:

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

a.m.
p.m.

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 41

Minutes

No

b. Name of city, town, or post office

L

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

Minute

35 How many minutes did it usually take this

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

37 During the LAST 4 WEEKS, has this person been

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

Yes

WEEK? If this person worked at more than one

No

No, because of own temporary illness

Yes ➔ SKIP to question 31

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

38 LAST WEEK, could this person have started a

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

No – Did not work (or retired)

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

Other method

50 or 60 percent
70 percent or higher

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

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

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 municipio in Puerto Rico
or U.S. county

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c
No

e. Enter Puerto Rico or name of U.S. state
or foreign country

f. ZIP Code

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
No ➔ SKIP to question 37

10

§.2|’¤

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

13179114

Person 1 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

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.)?

§.2|/¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city,
If net income was a loss, mark the "Loss" box to
county or muncipio)
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

$

Yes ➔
No

$

No

,

,

.00

,

TOTAL AMOUNT for past
12 months

g. Retirement income, pensions, survivor or
disability income. Include income from a
previous employer or union, or any regular
withdrawals or distributions from IRA, Roth IRA,
401(k), 403(b), or other accounts specifically
designed for retirement. Do NOT include Social
Security.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

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

$

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

$

None

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

,

,

TOTAL AMOUNT for past
12 months

.00

Loss

.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

13179122

Person 2

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?

GED or alternative credential

Yes, born in Puerto Rico ➔ SKIP to question 10a

COLLEGE OR SOME COLLEGE

Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree

Bachelor’s degree (for example: BA, BS)
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)

No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year

10 a. At any time IN THE LAST 3 MONTHS, has this

Doctorate degree (for example: PhD, EdD)

F

person attended school or college? Include

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

No, has not attended in the last 3
months ➔ SKIP to question 11

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Associate’s degree (for example: AA, AS)

AFTER BACHELOR’S DEGREE

9

For example: Korean, Italian, Spanish, Vietnamese

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

15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.

No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?

12 This question focuses on this person’s

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

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)

Address
Development or condominium name
Number and street name

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

§.2|7¤

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

Enter Puerto Rico or
name of U.S. state

ZIP Code

13179130

Person 2 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

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

g. Indian Health Service

No

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

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

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

I

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

serious difficulty hearing?
Yes

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

Less than 6 months
6 to 11 months

5 or more years

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

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

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

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

No

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

23 How many times has this person been married?

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

No

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

3 or 4 years

21 What is this person’s marital status?

No

Yes

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

No

Separated

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

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

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

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

Yes

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

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

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

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

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

On active duty in the past, but not now

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

§.2|?¤

13

13179148

Person 2 (continued)

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

29 a. Does this person have a VA service-connected
disability rating?

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

0 percent
10 or 20 percent

Carro público

30 or 40 percent

Ferryboat

Worked from
home ➔ SKIP
to question 40a

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

K

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

at a job (or business)?

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

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

Person(s)

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

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

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

days?

No ➔ SKIP to question 36a

Within the past 12 months

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

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

Hour

a. Address
Development or condominium name
Number and street name

:

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

a.m.
p.m.

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 41

Minutes

No

b. Name of city, town, or post office

L

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

Minute

35 How many minutes did it usually take this

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

37 During the LAST 4 WEEKS, has this person been

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

Yes

WEEK? If this person worked at more than one

No

No, because of own temporary illness

Yes ➔ SKIP to question 31

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

38 LAST WEEK, could this person have started a

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

No – Did not work (or retired)

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

Other method

50 or 60 percent
70 percent or higher

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

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

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 municipio in Puerto Rico
or U.S. county

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c
No

e. Enter Puerto Rico or name of U.S. state
or foreign country

f. ZIP Code

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
No ➔ SKIP to question 37

14

§.2|Q¤

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

13179155

Person 2 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

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.)?

§.2|X¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city,
If net income was a loss, mark the "Loss" box to
county or muncipio)
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

$

Yes ➔
No

$

No

,

,

.00

,

TOTAL AMOUNT for past
12 months

g. Retirement income, pensions, survivor or
disability income. Include income from a
previous employer or union, or any regular
withdrawals or distributions from IRA, Roth IRA,
401(k), 403(b), or other accounts specifically
designed for retirement. Do NOT include Social
Security.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

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

$

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

$

None

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

,

,

TOTAL AMOUNT for past
12 months

.00

Loss

.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

13179163

Person 3

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?

GED or alternative credential

Yes, born in Puerto Rico ➔ SKIP to question 10a

COLLEGE OR SOME COLLEGE

Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree

Bachelor’s degree (for example: BA, BS)
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)

No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year

10 a. At any time IN THE LAST 3 MONTHS, has this

Doctorate degree (for example: PhD, EdD)

F

person attended school or college? Include

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

No, has not attended in the last 3
months ➔ SKIP to question 11

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Associate’s degree (for example: AA, AS)

AFTER BACHELOR’S DEGREE

9

For example: Korean, Italian, Spanish, Vietnamese

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

15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.

No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?

12 This question focuses on this person’s

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

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)

Address
Development or condominium name
Number and street name

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

§.2|‘¤

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

Enter Puerto Rico or
name of U.S. state

ZIP Code

13179171

Person 3 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

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

g. Indian Health Service

No

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

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

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

I

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

serious difficulty hearing?
Yes

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

Less than 6 months
6 to 11 months

5 or more years

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

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

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

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

No

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

23 How many times has this person been married?

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

No

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

3 or 4 years

21 What is this person’s marital status?

No

Yes

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

No

Separated

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

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

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

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

Yes

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

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

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

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

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

On active duty in the past, but not now

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

§.2|h¤

17

13179189

Person 3 (continued)

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

29 a. Does this person have a VA service-connected
disability rating?

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

0 percent
10 or 20 percent

Carro público

30 or 40 percent

Ferryboat

Worked from
home ➔ SKIP
to question 40a

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

K

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

at a job (or business)?

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

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

Person(s)

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

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

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

days?

No ➔ SKIP to question 36a

Within the past 12 months

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

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

Hour

a. Address
Development or condominium name
Number and street name

:

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

a.m.
p.m.

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 41

Minutes

No

b. Name of city, town, or post office

L

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

Minute

35 How many minutes did it usually take this

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

37 During the LAST 4 WEEKS, has this person been

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

Yes

WEEK? If this person worked at more than one

No

No, because of own temporary illness

Yes ➔ SKIP to question 31

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

38 LAST WEEK, could this person have started a

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

No – Did not work (or retired)

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

Other method

50 or 60 percent
70 percent or higher

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

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

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 municipio in Puerto Rico
or U.S. county

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c
No

e. Enter Puerto Rico or name of U.S. state
or foreign country

f. ZIP Code

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
No ➔ SKIP to question 37

18

§.2|z¤

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

13179197

Person 3 (continued)
M

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

d. Social Security or Railroad Retirement.
Yes ➔

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

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

No
f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

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.)?

§.2|¿¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city,
If net income was a loss, mark the "Loss" box to
county or muncipio)
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

$

Yes ➔
No

$

No

,

,

.00

,

TOTAL AMOUNT for past
12 months

g. Retirement income, pensions, survivor or
disability income. Include income from a
previous employer or union, or any regular
withdrawals or distributions from IRA, Roth IRA,
401(k), 403(b), or other accounts specifically
designed for retirement. Do NOT include Social
Security.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

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

$

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

$

None

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

,

,

TOTAL AMOUNT for past
12 months

.00

Loss

.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

13179205

Person 4

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

➜

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

Please copy the name of Person 4 from page 3,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?

GED or alternative credential

Yes, born in Puerto Rico ➔ SKIP to question 10a

COLLEGE OR SOME COLLEGE

Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree

Bachelor’s degree (for example: BA, BS)
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)

No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year

10 a. At any time IN THE LAST 3 MONTHS, has this

Doctorate degree (for example: PhD, EdD)

F

person attended school or college? Include

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

No, has not attended in the last 3
months ➔ SKIP to question 11

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Associate’s degree (for example: AA, AS)

AFTER BACHELOR’S DEGREE

9

For example: Korean, Italian, Spanish, Vietnamese

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

15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.

No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?

12 This question focuses on this person’s

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

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)

Address
Development or condominium name
Number and street name

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

§.2}&¤

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

Enter Puerto Rico or
name of U.S. state

ZIP Code

13179213

Person 4 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

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

g. Indian Health Service

No

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

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

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

I

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

serious difficulty hearing?
Yes

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

Less than 6 months
6 to 11 months

5 or more years

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

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

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

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

No

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

23 How many times has this person been married?

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

No

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

3 or 4 years

21 What is this person’s marital status?

No

Yes

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

No

Separated

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

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

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

Yes

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

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

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

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

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

On active duty in the past, but not now

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

§.2}.¤

21

13179221

Person 4 (continued)

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

29 a. Does this person have a VA service-connected
disability rating?

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

0 percent
10 or 20 percent

Carro público

30 or 40 percent

Ferryboat

Worked from
home ➔ SKIP
to question 40a

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

K

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

at a job (or business)?

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

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

Person(s)

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

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

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

days?

No ➔ SKIP to question 36a

Within the past 12 months

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

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

Hour

a. Address
Development or condominium name
Number and street name

:

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

a.m.
p.m.

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 41

Minutes

No

b. Name of city, town, or post office

L

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

Minute

35 How many minutes did it usually take this

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

37 During the LAST 4 WEEKS, has this person been

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

Yes

WEEK? If this person worked at more than one

No

No, because of own temporary illness

Yes ➔ SKIP to question 31

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

38 LAST WEEK, could this person have started a

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

No – Did not work (or retired)

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

Other method

50 or 60 percent
70 percent or higher

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

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

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 municipio in Puerto Rico
or U.S. county

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c
No

e. Enter Puerto Rico or name of U.S. state
or foreign country

f. ZIP Code

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
No ➔ SKIP to question 37

22

§.2}6¤

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

13179239

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

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

No
f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

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.)?

§.2}H¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city,
If net income was a loss, mark the "Loss" box to
county or muncipio)
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

$

Yes ➔
No

$

No

,

,

.00

,

TOTAL AMOUNT for past
12 months

g. Retirement income, pensions, survivor or
disability income. Include income from a
previous employer or union, or any regular
withdrawals or distributions from IRA, Roth IRA,
401(k), 403(b), or other accounts specifically
designed for retirement. Do NOT include Social
Security.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

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

$

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

$

None

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

,

,

TOTAL AMOUNT for past
12 months

.00

Loss

.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

13179247

Person 5

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

➜

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

Please copy the name of Person 5 from page 4,
then continue answering questions below.
Last Name

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

Is this person a citizen of the United States?

GED or alternative credential

Yes, born in Puerto Rico ➔ SKIP to question 10a

COLLEGE OR SOME COLLEGE

Yes, born in a U.S. state, District of Columbia,
Guam, the U.S. Virgin Islands, or
Northern Marianas
Yes, born abroad of U.S. citizen parent
or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree

Bachelor’s degree (for example: BA, BS)
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)

No, not a U.S. citizen
When did this person come to live in
Puerto Rico? If this person came to live in
Puerto Rico more than once, print latest year.
Year

10 a. At any time IN THE LAST 3 MONTHS, has this

Doctorate degree (for example: PhD, EdD)

F

person attended school or college? Include

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

No, has not attended in the last 3
months ➔ SKIP to question 11

c. How well does this person speak English?
Very well
Well
Not well
Not at all

Associate’s degree (for example: AA, AS)

AFTER BACHELOR’S DEGREE

9

For example: Korean, Italian, Spanish, Vietnamese

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

15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to
question 16
Yes, this house ➔ SKIP to question 16
No, outside Puerto Rico and the
United States – Print name of foreign
country, or U.S. Virgin Islands, Guam, etc.,
below; then SKIP to question 16.

No, different house in Puerto Rico or the
United States
b. Where did this person live 1 year ago?

12 This question focuses on this person’s

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

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)

Address
Development or condominium name
Number and street name

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

§.2}P¤

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

Enter Puerto Rico or
name of U.S. state

ZIP Code

13179254

Person 5 (continued)

H

16 Is this person CURRENTLY covered by any of the

Answer questions 19a – c if this person is
5 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

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

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

g. Indian Health Service

No

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

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

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

I

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

serious difficulty hearing?
Yes

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

Less than 6 months
6 to 11 months

5 or more years

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

Now married
Widowed

Never served in the military ➔ SKIP to
question 30a

Never married ➔ SKIP to J

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

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

No

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

23 How many times has this person been married?

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

No

b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?

3 or 4 years

21 What is this person’s marital status?

No

Yes

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

No

Separated

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

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

1 or 2 years

No ➔ SKIP to question 18a

No

No

Yes

Divorced

Yes

Yes

No ➔ SKIP to question 27
Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

Yes

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

given birth to any children?

Yes

20 Because of a physical, mental, or emotional

G

25 In the PAST 12 MONTHS, has this person

No ➔ SKIP to question 27

No

f. VA (enrolled for VA health care)

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

Yes

Yes

e. TRICARE or other military health care

J

28 When did this person serve on active duty in the

U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.

September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)

Once

May 1975 to July 1990

Two times

Vietnam era (August 1964 to April 1975)

Three or more times

February 1955 to July 1964

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

On active duty in the past, but not now

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

§.2}W¤

25

13179262

Person 5 (continued)

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

29 a. Does this person have a VA service-connected
disability rating?

Car, truck, or van

Taxicab

Bus

Motorcycle

Subway or elevated rail

Bicycle

Long-distance train or
commuter rail

Walked

0 percent
10 or 20 percent

Carro público

30 or 40 percent

Ferryboat

Worked from
home ➔ SKIP
to question 40a

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

K

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

at a job (or business)?

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

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

Person(s)

ACTIVELY looking for work?
Yes
No ➔ SKIP to question 39

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

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

days?

No ➔ SKIP to question 36a

Within the past 12 months

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

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

Hour

a. Address
Development or condominium name
Number and street name

:

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

a.m.
p.m.

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.

person to get from home to work LAST WEEK?

Yes ➔ SKIP to question 41

Minutes

No

b. Name of city, town, or post office

L

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

Minute

35 How many minutes did it usually take this

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

37 During the LAST 4 WEEKS, has this person been

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

Yes

WEEK? If this person worked at more than one

No

No, because of own temporary illness

Yes ➔ SKIP to question 31

31 At what location did this person work LAST

Yes ➔ SKIP to question 38

38 LAST WEEK, could this person have started a

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

No – Did not work (or retired)

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

Other method

50 or 60 percent
70 percent or higher

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

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

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 municipio in Puerto Rico
or U.S. county

36 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 36c
No

e. Enter Puerto Rico or name of U.S. state
or foreign country

f. ZIP Code

b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
No ➔ SKIP to question 37

26

§.2}_¤

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

13179270

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

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

No
f. Describe this person’s most important
activities or duties. (For example: instruct
and evaluate students and create lesson plans,
assemble and install pipe sections and review
building plans for work details)

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.)?

§.2}g¤

TOTAL AMOUNT for past
12 months

Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

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

a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
43 INCOME IN THE PAST 12 MONTHS
Mark (X) ONE box.
Mark (X) the "Yes" box for each type of income this
PRIVATE SECTOR EMPLOYEE
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
For-profit company or organization
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
Non-profit organization (including
tax-exempt and charitable organizations)
Mark (X) the "No" box to show types of income
GOVERNMENT EMPLOYEE
NOT received.
Local government (for example: city,
If net income was a loss, mark the "Loss" box to
county or muncipio)
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

$

Yes ➔
No

$

No

,

,

.00

,

TOTAL AMOUNT for past
12 months

g. Retirement income, pensions, survivor or
disability income. Include income from a
previous employer or union, or any regular
withdrawals or distributions from IRA, Roth IRA,
401(k), 403(b), or other accounts specifically
designed for retirement. Do NOT include Social
Security.
Yes ➔
No

$

.00

,

TOTAL AMOUNT for past
12 months

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support
or alimony. Do NOT include lump sum payments
such as money from an inheritance or the sale of a
home.

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

$

.00

Yes ➔

TOTAL AMOUNT for past
12 months

$

.00

,

No

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

$

None

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Yes ➔
No

$

,

,

,

,

.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

13179288

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 Puerto Rico Community Survey.

For Census Bureau Use
POP

EDIT

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden estimate
or any other aspect of this collection of information,
including suggestions for reducing this burden, to:
Paperwork Project 0607-0810 and 0607-0936,
U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project
0607-0810 and 0607-0936" as the subject. Please
DO NOT RETURN your questionnaire to this address.
Use the enclosed preaddressed envelope to return your
completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.
This 8-digit number appears in the bottom right on the
front cover of this form.
Form ACS-1(2019)PR (02-02-2018)

28

§.2}y¤