ACS -1(X) CTC (06- The American Community Survey Content Test Control Quest

Attachment L1 -- ACS-1(X)CTC, Content Test Control Questionnaire

DC

13066014
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

THE

American Community Survey

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

➜

Please print today’s date.
Month
Day
Year

➜

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

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

MI

First Name

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

—

➜

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

➜

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

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

ACS-1(X)CTC

FORM
(06-09-2015) Draft 4 V2

§.’]/¤

OMB No. 0607-0936

13066022

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

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

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

Is Person 1 of Hispanic, Latino, or Spanish origin? Mark all boxes
that apply AND print origins. Note, you may report more than one group.

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Female

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

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

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

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

Mark all boxes
that apply AND print origins. Note, you may report more than one group.

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 details, for example,

Yes, another Hispanic, Latino, or Spanish origin – Print details, for example,

Salvadoran, Dominican, Colombian, etc. C

Salvadoran, Dominican, Colombian, etc. C

What is Person 1’s race? Mark all boxes that apply AND print origins in
the spaces below. Note, you may report more than one group.
White – Print details, for example, German, Lebanese, Egyptian, etc. C

6 What is Person 2’s race?

Mark all boxes that apply AND print origins in
the spaces below. Note, you may report more than one group.
White – Print details, for example, German, Lebanese, Egyptian, etc. C

Black or African Am. – Print details, for example, African American, Jamaican,

Black or African Am. – Print details, for example, African American, Jamaican,

Nigerian, etc. C

Nigerian, etc. C

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

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

Chinese

Vietnamese

Native Hawaiian

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Filipino

Korean

Samoan

Asian Indian

Japanese

Japanese

Chamorro

Chamorro

Asian Indian

Other Asian – Print details,

Other Pacific Islander – Print

Other Asian – Print details,

for example, Pakistani,
Cambodian, Hmong, etc. C

details, for example, Tongan,
Fijian, Marshallese, etc. C

for example, Pakistani,
Cambodian, Hmong, etc. C

Some other race – Print race(s) or origin(s).

2

Adopted son or daughter

Male

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

6

Other relative

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

What is Person 1’s age and what is Person 1’s date of birth?

5

Son-in-law or daughter-in-law

Biological son or daughter

Parent-in-law

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

Husband or wife

§.’]7¤

C

Some other race – Print race(s) or origin(s).

Other Pacific Islander – Print
details, for example, Tongan,
Fijian, Marshallese, etc. C
C

13066030

Person 3
1

1 What is Person 4’s name?

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

2

Person 4

First Name

MI

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

Husband or wife

Son-in-law or daughter-in-law

Other relative

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Brother or sister

Unmarried partner

Father or mother

Foster child

Father or mother

Foster child

Grandchild

Other nonrelative

Grandchild

Other nonrelative

Parent-in-law

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

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

Male

What is Person 3’s age and what is Person 3’s date of birth?

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

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

Is Person 3 of Hispanic, Latino, or Spanish origin? Mark all boxes
that apply AND print origins. Note, you may report more than one group.

6

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

Son-in-law or daughter-in-law

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

5

MI

Biological son or daughter

Male

4

First Name

Husband or wife

Parent-in-law

3

Last Name (Please print)

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?

Mark all boxes
that apply AND print origins. Note, you may report more than one group.

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 details, for example,

Yes, another Hispanic, Latino, or Spanish origin – Print details, for example,

Salvadoran, Dominican, Colombian, etc. C

Salvadoran, Dominican, Colombian, etc. C

What is Person 3’s race? Mark all boxes that apply AND print origins in
the spaces below. Note, you may report more than one group.
White – Print details, for example, German, Lebanese, Egyptian, etc. C

6 What is Person 4’s race?

Mark all boxes that apply AND print origins in
the spaces below. Note, you may report more than one group.
White – Print details, for example, German, Lebanese, Egyptian, etc. C

Black or African Am. – Print details, for example, African American, Jamaican,

Black or African Am. – Print details, for example, African American, Jamaican,

Nigerian, etc. C

Nigerian, etc. C

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

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

Chinese

Vietnamese

Native Hawaiian

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Filipino

Korean

Samoan

Asian Indian

Japanese

Japanese

Chamorro

Chamorro

Asian Indian

Other Asian – Print details,

Other Pacific Islander – Print

Other Asian – Print details,

for example, Pakistani,
Cambodian, Hmong, etc. C

details, for example, Tongan,
Fijian, Marshallese, etc. C

for example, Pakistani,
Cambodian, Hmong, etc. C

Some other race – Print race(s) or origin(s).

§.’]?¤

C

Some other race – Print race(s) or origin(s).

Other Pacific Islander – Print
details, for example, Tongan,
Fijian, Marshallese, etc. C
C

3

13066048

Person 5
1

➜

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

First Name

MI

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

Person 6
Last Name (Please print)

2

First Name

MI

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

Son-in-law or daughter-in-law

Biological son or daughter

Other relative

Adopted son or daughter

Roomer or boarder

Stepson or stepdaughter

Housemate or roommate

Brother or sister

Unmarried partner

Father or mother

Foster child

Grandchild

Other nonrelative

Sex

Male

Female

Age (in years)

Person 7
Last Name (Please print)

First Name

MI

Parent-in-law

3

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

4

Sex

Female

Male

Female

Age (in years)

Person 8

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

Last Name (Please print)

Sex

Male

First Name

Female

MI

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? Mark all boxes
that apply AND print origins. Note, you may report more than one group.

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
Sex

Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print details, for example,
Salvadoran, Dominican, Colombian, etc. C

Male

Female

Person 10
Last Name (Please print)

6

Age (in years)

First Name

MI

What is Person 5’s race? Mark all boxes that apply AND print origins in
the spaces below. Note, you may report more than one group.
White – Print details, for example, German, Lebanese, Egyptian, etc. C
Sex
Black or African Am. – Print details, for example, African American, Jamaican,
Nigerian, etc. C

Male

Female

Age (in years)

Person 11
Last Name (Please print)

First Name

MI

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian – Print details,
for example, Pakistani,
Cambodian, Hmong, etc. C
Some other race – Print race(s) or origin(s).

4

§.’]Q¤

Other Pacific Islander – Print
details, for example, Tongan,
Fijian, Marshallese, etc. C
C

Sex

Male

Female

Age (in years)

Person 12
Last Name (Please print)

Sex

Male

First Name

Female

Age (in years)

MI

13066055

Housing
➜

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

A

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

Which best describes this building?
Include all apartments, flats, etc., even if
vacant.
A mobile home
A one-family house detached from any
other house
A one-family house attached to one or
more houses
A building with 2 apartments

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

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

A building with 3 or 4 apartments

None

A building with 5 to 9 apartments

$1 to $999

A building with 10 to 19 apartments

$1,000 to $2,499

A building with 20 to 49 apartments

$2,500 to $4,999

A building with 50 or more apartments

$5,000 to $9,999

Boat, RV, van, etc.

$10,000 or more

6 a. How many separate rooms are in this
2

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

Yes

No

a. hot and cold running water?

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.

c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?

8 Can you or any member of this household
both make and receive phone calls when at
this house, apartment, or mobile home?
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 computers?
• EXCLUDE GPS devices, digital music players,
and devices with only limited computing
capabilities, for example: household
appliances.
Yes
No
a. Desktop, laptop, netbook, or
notebook computer
b. Handheld computer,
smart mobile phone, or other
handheld wireless computer
c. Some other type of computer
Specify

1990 to 1999

• INCLUDE bedrooms, kitchens, etc.
10 At this house, apartment, or mobile home –
• EXCLUDE bathrooms, porches, balconies,
do you or any member of this household
foyers, halls, or unfinished basements.
access the Internet?

1980 to 1989

Number of rooms

1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1939 or earlier

3

home have –

b. a bathtub or shower?
mobile home on?

1

7 Does this house, apartment, or mobile

Yes, with a subscription to an Internet
service
Yes, without a subscription to an Internet
service ➔ SKIP to question 12

b. How many of these rooms are bedrooms?
No Internet access at this house, apartment,
Count as bedrooms those rooms you would
or mobile home ➔ SKIP to question 12
list if this house, apartment, or mobile home
were for sale or rent. If this is an
11 At this house, apartment, or mobile home –
efficiency/studio apartment, print "0".
do you or any member of this household
subscribe to the Internet using –
Number of bedrooms
Yes
No
a. Dial-up service?

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

Year

b. DSL service?
c. Cable modem service?
d. Fiber-optic service?
e. Mobile broadband plan for
a computer or a cell phone?
f. Satellite Internet service?
g. Some other service?
Specify service

§.’]X¤

5

13066063

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

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

$

.00

,

None

OR

1

No

No charge or electricity not used

16 Is this house, apartment, or mobile home

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

4
5

Last month’s cost – Dollars

6 or more

$

.00

,

house, apartment, or mobile home?

Monthly amount – Dollars

Wood
Solar energy
Other fuel

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

$

.00

,

No fuel used

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

$

.00

,
OR

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

§.’]‘¤

$

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

Electricity

Coal or coke

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

Included in rent or condominium fee

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

Fuel oil, kerosene, etc.

part of a condominium?

OR

13 Which FUEL is used MOST for heating this

6

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

Included in rent or condominium fee

2

15 IN THE PAST 12 MONTHS, did you or

.00

,
OR
None

No

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

13066071

Housing (continued)
B

Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.

22 a. Do you or any member of this

23 a. Do you or any member of this
household have a second mortgage
or a home equity loan on THIS
property?

household have a mortgage, deed of
trust, contract to purchase, or similar
debt on THIS property?

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

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

Yes, home equity loan

No ➔ SKIP to question 23a

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

Yes, second mortgage

Monthly amount – Dollars

$

.00

,

b. Does the monthly rent include any
meals?

No

19 About how much do you think this
house and lot, apartment, or mobile
home (and lot, if owned) would sell for
if it were for sale?

.00

,

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

$

,

Monthly amount – Dollars

.00

$

.00

OR

No regular payment required ➔ SKIP to
question 23a
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?

,

No regular payment required

D

Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required

Answer question 24 if this is a MOBILE
HOME. Otherwise, SKIP to E .

24 What are the total annual costs for

Amount – Dollars

,

,
OR

Answer questions 19 – 23 if you or any
member of this household OWNS
or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E .

$

b. How much is the regular monthly
payment on all second or junior
mortgages and all home equity loans
on THIS property?

Monthly amount – Dollars

$

Yes

C

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

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

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

Annual costs – Dollars

Yes, insurance included in mortgage
payment
No, insurance paid separately or no
insurance

$

,

.00

.00
E

OR
None

Answer questions about PERSON 1 on the
next page if you listed at least one person
on page 2. Otherwise, SKIP to page 28 for
the mailing instructions.

21 What is the annual payment for fire,
hazard, and flood insurance on THIS
property?
Annual amount – Dollars

$

.00

,
OR
None

§.’]h¤

7

13066089

Person 1

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

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

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

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

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

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

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

program, or medical or law school)

8

§.’]z¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13066097

Person 1 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Yes

g. Indian Health Service

No

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

G

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

I

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.

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

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
serious difficulty hearing?
Yes

Yes
No

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 27

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?

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

Less than 6 months
6 to 11 months
1 or 2 years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to
question 30a

Divorced
Separated

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

Never married ➔ SKIP to J

Now on active duty

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

No

a. Married?

c. Divorced?

23 How many times has this person been married?

On active duty in the past, but not now

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

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

5 or more years

Widowed

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

No

No

Now married

No

Yes

3 or 4 years

b. Widowed?

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

the past 12 months?

Yes

21 What is this person’s marital status?

No ➔ SKIP to question 18a

25 Has this person given birth to any children in

No ➔ SKIP to question 27

20 Because of a physical, mental, or emotional

Yes

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

Yes

Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 2 on page 12.

17 a. Is there a premium for this plan? A premium

J

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

§.’]¿¤

9

13066105

Person 1 (continued)

32 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

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

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

Car, truck, or van

Motorcycle

Yes ➔ SKIP to question 38

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated

0 percent

Railroad

Worked at
home ➔ SKIP
to question 40a

10 or 20 percent

Ferryboat

Other method

30 or 40 percent

Taxicab

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

38 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

50 or 60 percent
70 percent or higher

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

K

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

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

Yes, could have gone to work
No, because of own temporary illness

at a job (or business)?
No, because of all other reasons (in school, etc.)
Yes ➔ SKIP to question 31

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

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

Person(s)

days?
Within the past 12 months

Yes

1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

31 At what location did this person work LAST

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

34 What time did this person usually leave home
to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

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

Minute

:

a. Address (Number and street name)

a.m.
p.m.

Over 5 years ago or never worked ➔ SKIP to
question 48

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 41

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

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

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

Minutes

b. Name of city, town, or post office

50 to 52 weeks

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

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

d. Name of county

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

e. 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

§.’^&¤

40 to 47 weeks
27 to 39 weeks

Yes
No, outside the city/town limits

48 to 49 weeks

14 to 26 weeks
13 weeks or less

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

13066113

Person 1 (continued)
M

Answer questions 42 – 47 if this person
worked in the past 5 years. Otherwise,
SKIP to question 48.

42 – 47 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

46 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

43 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

No

Name of company, business, or other employer

44 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

$

,

,

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.

.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
49 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 48a
Yes ➔

$

No

,

,

to 48h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

45 Is this mainly – Mark (X) ONE box.

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

a Federal GOVERNMENT employee?

working WITHOUT PAY in family business
or farm?

$

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

48 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

e. Supplemental Security Income (SSI).

47 What were this person’s most important

42 Was this person –
Mark (X) ONE box.

$

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

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

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

§.’^.¤

Yes ➔
No

$

,

,

.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

13066121

Person 2

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

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

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

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

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

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

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

program, or medical or law school)

12

§.’^6¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13066139

Person 2 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Yes

g. Indian Health Service

No

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

G

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

I

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.

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

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
serious difficulty hearing?
Yes

Yes
No

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 27

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?

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

Less than 6 months
6 to 11 months
1 or 2 years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to
question 30a

Divorced
Separated

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

Never married ➔ SKIP to J

Now on active duty

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

No

a. Married?

c. Divorced?

23 How many times has this person been married?

On active duty in the past, but not now

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

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

5 or more years

Widowed

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

No

No

Now married

No

Yes

3 or 4 years

b. Widowed?

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

the past 12 months?

Yes

21 What is this person’s marital status?

No ➔ SKIP to question 18a

25 Has this person given birth to any children in

No ➔ SKIP to question 27

20 Because of a physical, mental, or emotional

Yes

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

Yes

Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 3 on page 16.

17 a. Is there a premium for this plan? A premium

J

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

§.’^H¤

13

13066147

Person 2 (continued)

32 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

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

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

Car, truck, or van

Motorcycle

Yes ➔ SKIP to question 38

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated

0 percent

Railroad

Worked at
home ➔ SKIP
to question 40a

10 or 20 percent

Ferryboat

Other method

30 or 40 percent

Taxicab

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

38 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

50 or 60 percent
70 percent or higher

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

K

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

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

Yes, could have gone to work
No, because of own temporary illness

at a job (or business)?
No, because of all other reasons (in school, etc.)
Yes ➔ SKIP to question 31

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

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

Person(s)

days?
Within the past 12 months

Yes

1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

31 At what location did this person work LAST

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

34 What time did this person usually leave home
to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

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

Minute

:

a. Address (Number and street name)

a.m.
p.m.

Over 5 years ago or never worked ➔ SKIP to
question 48

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 41

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

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

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

Minutes

b. Name of city, town, or post office

50 to 52 weeks

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

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

d. Name of county

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

e. 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

§.’^P¤

40 to 47 weeks
27 to 39 weeks

Yes
No, outside the city/town limits

48 to 49 weeks

14 to 26 weeks
13 weeks or less

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

13066154

Person 2 (continued)
M

Answer questions 42 – 47 if this person
worked in the past 5 years. Otherwise,
SKIP to question 48.

42 – 47 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

46 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

43 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

No

Name of company, business, or other employer

44 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

$

,

,

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.

.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
49 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 48a
Yes ➔

$

No

,

,

to 48h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

45 Is this mainly – Mark (X) ONE box.

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

a Federal GOVERNMENT employee?

working WITHOUT PAY in family business
or farm?

$

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

48 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

e. Supplemental Security Income (SSI).

47 What were this person’s most important

42 Was this person –
Mark (X) ONE box.

$

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

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

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

§.’^W¤

Yes ➔
No

$

,

,

.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

13066162

Person 3

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

➜

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

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

NO SCHOOLING COMPLETED

No schooling completed
First Name

NURSERY OR PRESCHOOL THROUGH GRADE 12

MI

Nursery school
Kindergarten

7

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

Where was this person born?

Grade 1 through 11 – Specify
grade 1 – 11

In the United States – Print name of state.

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

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

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

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

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

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

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

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

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

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

program, or medical or law school)

16

§.’^_¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13066170

Person 3 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

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

e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Yes

g. Indian Health Service

No

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

G

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

I

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.

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

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
serious difficulty hearing?
Yes

Yes
No

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 27

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?

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

Less than 6 months
6 to 11 months
1 or 2 years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to
question 30a

Divorced
Separated

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

Never married ➔ SKIP to J

Now on active duty

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

No

a. Married?

c. Divorced?

23 How many times has this person been married?

On active duty in the past, but not now

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

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

5 or more years

Widowed

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

No

No

Now married

No

Yes

3 or 4 years

b. Widowed?

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

the past 12 months?

Yes

21 What is this person’s marital status?

No ➔ SKIP to question 18a

25 Has this person given birth to any children in

No ➔ SKIP to question 27

20 Because of a physical, mental, or emotional

Yes

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

Yes

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

17 a. Is there a premium for this plan? A premium

J

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

§.’^g¤

17

13066188

Person 3 (continued)

32 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

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

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

Car, truck, or van

Motorcycle

Yes ➔ SKIP to question 38

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated

0 percent

Railroad

Worked at
home ➔ SKIP
to question 40a

10 or 20 percent

Ferryboat

Other method

30 or 40 percent

Taxicab

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

38 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

50 or 60 percent
70 percent or higher

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

K

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

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

Yes, could have gone to work
No, because of own temporary illness

at a job (or business)?
No, because of all other reasons (in school, etc.)
Yes ➔ SKIP to question 31

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

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

Person(s)

days?
Within the past 12 months

Yes

1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

31 At what location did this person work LAST

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

34 What time did this person usually leave home
to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

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

Minute

:

a. Address (Number and street name)

a.m.
p.m.

Over 5 years ago or never worked ➔ SKIP to
question 48

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 41

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

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

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

Minutes

b. Name of city, town, or post office

50 to 52 weeks

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

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

d. Name of county

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

e. 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

§.’^y¤

40 to 47 weeks
27 to 39 weeks

Yes
No, outside the city/town limits

48 to 49 weeks

14 to 26 weeks
13 weeks or less

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

13066196

Person 3 (continued)
M

Answer questions 42 – 47 if this person
worked in the past 5 years. Otherwise,
SKIP to question 48.

42 – 47 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

46 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

43 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

No

Name of company, business, or other employer

44 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

$

,

,

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.

.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
49 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 48a
Yes ➔

$

No

,

,

to 48h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

45 Is this mainly – Mark (X) ONE box.

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

a Federal GOVERNMENT employee?

working WITHOUT PAY in family business
or farm?

$

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

48 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

e. Supplemental Security Income (SSI).

47 What were this person’s most important

42 Was this person –
Mark (X) ONE box.

$

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

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

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

§.’^£¤

Yes ➔
No

$

,

,

.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

13066204

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 name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

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

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

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

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

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

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

program, or medical or law school)

20

§.’_%¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13066212

Person 4 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Yes

g. Indian Health Service

No

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

G

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

I

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.

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

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
serious difficulty hearing?
Yes

Yes
No

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 27

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?

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

Less than 6 months
6 to 11 months
1 or 2 years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to
question 30a

Divorced
Separated

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

Never married ➔ SKIP to J

Now on active duty

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

No

a. Married?

c. Divorced?

23 How many times has this person been married?

On active duty in the past, but not now

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

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

5 or more years

Widowed

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

No

No

Now married

No

Yes

3 or 4 years

b. Widowed?

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

the past 12 months?

Yes

21 What is this person’s marital status?

No ➔ SKIP to question 18a

25 Has this person given birth to any children in

No ➔ SKIP to question 27

20 Because of a physical, mental, or emotional

Yes

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

Yes

Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the questions for Person 5 on page 24.

17 a. Is there a premium for this plan? A premium

J

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

§.’_-¤

21

13066220

Person 4 (continued)

32 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

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

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

Car, truck, or van

Motorcycle

Yes ➔ SKIP to question 38

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated

0 percent

Railroad

Worked at
home ➔ SKIP
to question 40a

10 or 20 percent

Ferryboat

Other method

30 or 40 percent

Taxicab

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

38 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

50 or 60 percent
70 percent or higher

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

K

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

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

Yes, could have gone to work
No, because of own temporary illness

at a job (or business)?
No, because of all other reasons (in school, etc.)
Yes ➔ SKIP to question 31

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

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

Person(s)

days?
Within the past 12 months

Yes

1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

31 At what location did this person work LAST

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

34 What time did this person usually leave home
to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

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

Minute

:

a. Address (Number and street name)

a.m.
p.m.

Over 5 years ago or never worked ➔ SKIP to
question 48

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 41

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

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

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

Minutes

b. Name of city, town, or post office

50 to 52 weeks

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

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

d. Name of county

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

e. 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

§.’_5¤

40 to 47 weeks
27 to 39 weeks

Yes
No, outside the city/town limits

48 to 49 weeks

14 to 26 weeks
13 weeks or less

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

13066238

Person 4 (continued)
M

Answer questions 42 – 47 if this person
worked in the past 5 years. Otherwise,
SKIP to question 48.

42 – 47 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

46 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

43 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

No

Name of company, business, or other employer

44 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

$

,

,

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.

.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
49 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 48a
Yes ➔

$

No

,

,

to 48h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

45 Is this mainly – Mark (X) ONE box.

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

a Federal GOVERNMENT employee?

working WITHOUT PAY in family business
or farm?

$

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

48 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

e. Supplemental Security Income (SSI).

47 What were this person’s most important

42 Was this person –
Mark (X) ONE box.

$

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

$

,

,

TOTAL AMOUNT for past
12 months

.00
Loss

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

§.’_G¤

Yes ➔
No

$

,

,

.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

13066246

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 name of
foreign country, or Puerto Rico, Guam, etc.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Regular high school diploma

8

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

GED or alternative credential
COLLEGE OR SOME COLLEGE

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

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

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

1 or more years of college credit, no degree

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

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

No, not a U.S. citizen

9

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

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

Year

Doctorate degree (for example: PhD, EdD)

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

F

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

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

Very well
Well
Not well
Not at all

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

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

No, different house in the United States or
Puerto Rico

Address (Number and street name)

12 This question focuses on this person’s

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

c. How well does this person speak English?

b. Where did this person live 1 year ago?

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

For example: Korean, Italian, Spanish, Vietnamese

BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)

Name of city, town, or post office

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

College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD

program, or medical or law school)

24

§.’_O¤

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

Name of U.S. state or
Puerto Rico

ZIP Code

13066253

Person 5 (continued)

H

16 Is this person CURRENTLY covered by any of the

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

e. TRICARE or other military health care
f. VA (including those who have ever
used or enrolled for VA health care)

Yes

g. Indian Health Service

No

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

G

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

I

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.

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

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
serious difficulty hearing?
Yes

Yes
No

grandchildren under the age of 18 living in
this house or apartment?
Yes
No ➔ SKIP to question 27

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?

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

Less than 6 months
6 to 11 months
1 or 2 years

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Never served in the military ➔ SKIP to
question 30a

Divorced
Separated

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

Never married ➔ SKIP to J

Now on active duty

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

No

a. Married?

c. Divorced?

23 How many times has this person been married?

On active duty in the past, but not now

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

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

5 or more years

Widowed

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

No

No

Now married

No

Yes

3 or 4 years

b. Widowed?

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

the past 12 months?

Yes

21 What is this person’s marital status?

No ➔ SKIP to question 18a

25 Has this person given birth to any children in

No ➔ SKIP to question 27

20 Because of a physical, mental, or emotional

Yes

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

Yes

Answer question 20 if this person is
15 years old or over. Otherwise, SKIP to
the mailing instructions on page 28.

17 a. Is there a premium for this plan? A premium

J

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

§.’_V¤

25

13066261

Person 5 (continued)

32 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

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

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

Car, truck, or van

Motorcycle

Yes ➔ SKIP to question 38

Bus or trolley bus

Bicycle

No

Streetcar or trolley car

Walked

Subway or elevated

0 percent

Railroad

Worked at
home ➔ SKIP
to question 40a

10 or 20 percent

Ferryboat

Other method

30 or 40 percent

Taxicab

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

38 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?

50 or 60 percent
70 percent or higher

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

K

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

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

Yes, could have gone to work
No, because of own temporary illness

at a job (or business)?
No, because of all other reasons (in school, etc.)
Yes ➔ SKIP to question 31

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

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

Person(s)

days?
Within the past 12 months

Yes

1 to 5 years ago ➔ SKIP to M

No ➔ SKIP to question 36a

31 At what location did this person work LAST

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

34 What time did this person usually leave home
to go to work LAST WEEK?

WEEK? If this person worked at more than one

Hour

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

Minute

:

a. Address (Number and street name)

a.m.
p.m.

Over 5 years ago or never worked ➔ SKIP to
question 48

40 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
paid time off as work.
Yes ➔ SKIP to question 41

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

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

No
b. How many weeks DID this person work, even
for a few hours, including paid vacation, paid
sick leave, and military service?

Minutes

b. Name of city, town, or post office

50 to 52 weeks

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

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

d. Name of county

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

e. 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

§.’_^¤

40 to 47 weeks
27 to 39 weeks

Yes
No, outside the city/town limits

48 to 49 weeks

14 to 26 weeks
13 weeks or less

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

13066279

Person 5 (continued)
M

Answer questions 42 – 47 if this person
worked in the past 5 years. Otherwise,
SKIP to question 48.

42 – 47 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

46 What kind of work was this person doing?

d. Social Security or Railroad Retirement.

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes ➔
No

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes ➔
No

a local GOVERNMENT employee
(city, county, etc.)?

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

a state GOVERNMENT employee?

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

43 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.

No

Name of company, business, or other employer

44 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

$

,

,

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.

.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
49 What was this person’s total income during the
NET income after business expenses.
PAST 12 MONTHS? Add entries in questions 48a
Yes ➔

$

No

,

,

to 48h; subtract any losses. If net income was a loss,
enter the amount and mark (X) the "Loss" box next to
the dollar amount.

.00

TOTAL AMOUNT for past
12 months

Loss

OR
None

45 Is this mainly – Mark (X) ONE box.

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

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

No

$

g. Retirement, survivor, or disability pensions.
Do NOT include Social Security.

For income received jointly, report the appropriate
share for each person – or, if that’s not possible,
report the whole amount for only one person and
mark the "No" box for the other person.

Yes ➔

.00

,

TOTAL AMOUNT for past
12 months

Yes ➔

a Federal GOVERNMENT employee?

working WITHOUT PAY in family business
or farm?

$

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

48 INCOME IN THE PAST 12 MONTHS

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?

TOTAL AMOUNT for past
12 months

activities or duties? (For example: patient care,

Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

.00

,

e. Supplemental Security Income (SSI).

47 What were this person’s most important

42 Was this person –
Mark (X) ONE box.

$

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

$

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

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

§.’_p¤

Yes ➔
No

$

,

,

.00

TOTAL AMOUNT for past
12 months

Loss

➜

Now continue with the mailing instructions
on page 28.

27

13066287

Mailing
Instructions
➜ Please make sure you have...

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

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

For Census Bureau Use
POP

EDIT

EDIT CLERK

PHONE

TELEPHONE CLERK

JIC1

JIC2

JIC3

JIC4

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

28

§.’_x¤