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U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
TM
2020 Census of American Samoa
American Samoa
FOR NPC
USE ONLY
Census Office
Enter ID Number from Barcode Label on the D-Q-AS for this household.
County
BCU
Within Map Spot ID
R
AF
T
Map Spot
11830015
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D
CONTINUATION QUESTIONNAIRE
FORM
D-CQ-AS (11-19-2018) Draft 14
1.
What is the name of Person
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
First Name
MI
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Last Name(s)
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Yes, Cuban
Does this person usually live or stay somewhere else?
For example –
J all that apply.
I
Mark K
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For another reason
For a job or business
No
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
In a nursing home
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
T
3.
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
D
Father or mother
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Grandchild
Parent-in-law
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Son-in-law or daughter-in-law
Other relative
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Roommate or housemate
Foster child
Some other race – Print race or origin. C
Other nonrelative
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
11830023
§,t!8¤
Chinese
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
years
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the
D-Q-AS, continue with the next person on the next
page. Otherwise, skip to page 7 of the D-Q-AS.
Page 2 – Person
1.
What is the name of Person
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
First Name
MI
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Last Name(s)
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Yes, Cuban
Does this person usually live or stay somewhere else?
For example –
J all that apply.
I
Mark K
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
For another reason
No
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
In a nursing home
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
T
3.
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
D
Father or mother
Grandchild
Parent-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Son-in-law or daughter-in-law
Other relative
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Roommate or housemate
11830031
Foster child
Some other race – Print race or origin. C
Other nonrelative
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
years
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the
D-Q-AS, continue with the next person on the next
page. Otherwise, skip to page 7 of the D-Q-AS.
Page 3 – Person
§,t!@¤
Biological son or daughter
1.
What is the name of Person
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
First Name
MI
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Last Name(s)
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Yes, Cuban
Does this person usually live or stay somewhere else?
For example –
J all that apply.
I
Mark K
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For another reason
For a job or business
No
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
In a nursing home
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
T
3.
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
D
Father or mother
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Grandchild
Parent-in-law
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Son-in-law or daughter-in-law
Other relative
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Roommate or housemate
Foster child
Some other race – Print race or origin. C
Other nonrelative
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
11830049
§,t!R¤
Chinese
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
years
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the
D-Q-AS, continue with the next person on the next
page. Otherwise, skip to page 7 of the D-Q-AS.
Page 4 – Person
1.
What is the name of Person
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
First Name
MI
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Last Name(s)
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Yes, Cuban
Does this person usually live or stay somewhere else?
For example –
J all that apply.
I
Mark K
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
For another reason
No
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
In a nursing home
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
T
3.
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
D
Father or mother
Grandchild
Parent-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Son-in-law or daughter-in-law
Other relative
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Roommate or housemate
11830056
Foster child
Some other race – Print race or origin. C
Other nonrelative
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
years
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the
D-Q-AS, continue with the next person on the next
page. Otherwise, skip to page 7 of the D-Q-AS.
Page 5 – Person
§,t!Y¤
Biological son or daughter
1.
What is the name of Person
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
First Name
MI
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Last Name(s)
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Yes, Cuban
Does this person usually live or stay somewhere else?
For example –
J all that apply.
I
Mark K
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For another reason
For a job or business
No
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
In a nursing home
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
T
3.
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
D
Father or mother
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Grandchild
Parent-in-law
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Son-in-law or daughter-in-law
Other relative
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Roommate or housemate
Foster child
Some other race – Print race or origin. C
Other nonrelative
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
11830064
§,t!a¤
Chinese
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
years
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the front
page of the D-Q-AS, continue with the next person on
an additional continuation questionnaire (D-CQ-AS)
and update the number of continuation questionnaires
on page 1 of the D-Q-AS.
Page 6 – Person
Person —
12.
Please copy the name of the Person listed on page 2, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Last Name(s)
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
8.
Is this person a citizen or national of the United States?
Grade 1 through 11 – Specify grade 1 – 11
C
Yes, born in American Samoa ➜ SKIP to question 11a
Yes, born in another U.S. state or U.S. territory
12th grade – NO DIPLOMA
Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
No, not a U.S. citizen or U.S. national (temporary resident)
Where was this person born?
Print name of U.S. state, U.S. territory, or foreign country.
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
R
AF
9.
COLLEGE OR SOME COLLEGE
T
No, not a U.S. citizen or U.S. national (permanent resident)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Year
Doctorate degree (for example: PhD, EdD)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary school,
home school, and schooling which leads to a high school
diploma or a college degree.
Yes
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
A
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
11830072
Public school or public college
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Yes
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
No
C
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)
7
§,t!i¤
11.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
D
10.
Person — (continued)
15.
19.
What is this person’s ancestry or ethnic origin?
What was this person’s main reason for moving?
Mark K
J ONE box.
I
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
20.
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
T
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
17.
R
AF
f. VA (enrolled for VA health care)
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
Well
Not well
Not at all
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Yes
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
11830080
§,t!q¤
18.
No
D
Very well
a. Is this person deaf or does he/she have serious difficulty
hearing?
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
8
Person — (continued)
26.
How many times has this person been married?
Once
B
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for the next person on
page 13.
Three or more times
27.
22.
In what year did this person last get married?
Year
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
Yes
D
No
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
No
None or
Number of children
c. Does this person have difficulty dressing or bathing?
No
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
T
29.
Yes
Yes
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for the next person on
page 13.
23.
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?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No
24.
No ➜ SKIP to question 30
R
AF
C
Yes
No ➜ SKIP to question 30
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.
What is this person’s marital status?
Less than 6 months
D
Now married
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to D
5 or more years
§,t!¥¤
25.
Widowed
In the PAST 12 MONTHS did this person get –
Yes
No
11830098
a. Married?
b. Widowed?
c. Divorced?
9
Person — (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
On active duty in the past, but not now
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
R
AF
Korean War (July 1950 to January 1955)
January 1947 to June 1950
T
31.
35.
World War II (December 1941 to December 1946)
November 1941 or earlier
32.
a. Does this person have a VA service-connected
disability rating?
Other method
E
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
Yes (such as 0%, 10%, 20%, ..., 100%)
36.
b. What is this person’s service-connected disability rating?
0 percent
D
10 or 20 percent
30 or 40 percent
§,t"’¤
33.
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
37.
50 or 60 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
70 percent or higher
Hour
Minute
:
a. LAST WEEK, did this person work for pay at a job
(or business)?
38.
a.m.
p.m.
Yes ➜ SKIP to question 34
How many minutes did it usually take this person to get
from home to work LAST WEEK?
No – Did not work (or retired)
Minutes
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
10
11830106
No ➜ SKIP to question 33a
Person — (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
F
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
G
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
45.
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
R
AF
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Yes, could have gone to work
Federal government civilian employee
No, because of own temporary illness
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice,
or farm
D
42.
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to G
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
11830114
No ➜ SKIP to G
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
11
§,t"/¤
40.
T
Yes ➜ SKIP to question 41
No
DESCRIPTION OF EMPLOYMENT
Person — (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
T
TOTAL AMOUNT – Dollars
$
.00
No
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. 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. Mark K
J the "No"
I
box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
Yes ➜ What was the amount from all jobs before deductions
for taxes, bonds, dues, or other items?
D
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
§,t"7¤
No
.00
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
$
47.
OR
Loss
None
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
No
What was this person’s total income for 2019?
.00
No
.00
No
Yes ➜ What was the net income after business expenses?
TOTAL AMOUNT – Dollars
.00
No
.00
Loss
12
$
.00
TOTAL AMOUNT for 2019
Loss
11830122
INCOME IN 2019
R
AF
46.
Person —
12.
Please copy the name of the Person listed on page 3, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Last Name(s)
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
8.
Is this person a citizen or national of the United States?
Grade 1 through 11 – Specify grade 1 – 11
C
Yes, born in American Samoa ➜ SKIP to question 11a
Yes, born in another U.S. state or U.S. territory
12th grade – NO DIPLOMA
Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
No, not a U.S. citizen or U.S. national (temporary resident)
Where was this person born?
Print name of U.S. state, U.S. territory, or foreign country.
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
R
AF
9.
COLLEGE OR SOME COLLEGE
T
No, not a U.S. citizen or U.S. national (permanent resident)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Year
Doctorate degree (for example: PhD, EdD)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary school,
home school, and schooling which leads to a high school
diploma or a college degree.
Yes
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
A
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
11830130
Public school or public college
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Yes
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
No
C
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)
13
§,t"?¤
11.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
D
10.
Person — (continued)
15.
19.
What is this person’s ancestry or ethnic origin?
What was this person’s main reason for moving?
Mark K
J ONE box.
I
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
T
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
e. TRICARE or other military health care
17.
R
AF
f. VA (enrolled for VA health care)
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
Well
Not well
Not at all
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Yes
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
11830148
§,t"Q¤
18.
No
D
Very well
a. Is this person deaf or does he/she have serious difficulty
hearing?
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
14
Person — (continued)
26.
How many times has this person been married?
Once
B
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for the next person on
page 19.
Three or more times
27.
22.
In what year did this person last get married?
Year
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
Yes
D
No
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
No
None or
Number of children
c. Does this person have difficulty dressing or bathing?
No
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
T
29.
Yes
Yes
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for the next person on
page 19.
23.
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?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No
24.
No ➜ SKIP to question 30
R
AF
C
Yes
No ➜ SKIP to question 30
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.
What is this person’s marital status?
Less than 6 months
D
Now married
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to D
5 or more years
§,t"X¤
25.
Widowed
In the PAST 12 MONTHS did this person get –
Yes
No
11830155
a. Married?
b. Widowed?
c. Divorced?
15
Person — (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
On active duty in the past, but not now
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
R
AF
Korean War (July 1950 to January 1955)
January 1947 to June 1950
T
31.
35.
World War II (December 1941 to December 1946)
November 1941 or earlier
32.
a. Does this person have a VA service-connected
disability rating?
Other method
E
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
Yes (such as 0%, 10%, 20%, ..., 100%)
36.
b. What is this person’s service-connected disability rating?
0 percent
D
10 or 20 percent
30 or 40 percent
§,t"‘¤
33.
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
37.
50 or 60 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
70 percent or higher
Hour
Minute
:
a. LAST WEEK, did this person work for pay at a job
(or business)?
38.
a.m.
p.m.
Yes ➜ SKIP to question 34
How many minutes did it usually take this person to get
from home to work LAST WEEK?
No – Did not work (or retired)
Minutes
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
16
11830163
No ➜ SKIP to question 33a
Person — (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
F
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
G
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
45.
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
R
AF
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Yes, could have gone to work
Federal government civilian employee
No, because of own temporary illness
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice,
or farm
D
42.
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to G
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
11830171
No ➜ SKIP to G
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
17
§,t"h¤
40.
T
Yes ➜ SKIP to question 41
No
DESCRIPTION OF EMPLOYMENT
Person — (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
T
TOTAL AMOUNT – Dollars
$
.00
46.
INCOME IN 2019
R
AF
No
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. 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. Mark K
J the "No"
I
box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before deductions
for taxes, bonds, dues, or other items?
D
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
.00
No
OR
Loss
None
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
No
What was this person’s total income for 2019?
.00
Loss
18
$
.00
TOTAL AMOUNT for 2019
Loss
11830189
§,t"z¤
No
.00
No
Person —
12.
Please copy the name of the Person listed on page 4, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Last Name(s)
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
8.
Is this person a citizen or national of the United States?
Grade 1 through 11 – Specify grade 1 – 11
C
Yes, born in American Samoa ➜ SKIP to question 11a
Yes, born in another U.S. state or U.S. territory
12th grade – NO DIPLOMA
Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
No, not a U.S. citizen or U.S. national (temporary resident)
Where was this person born?
Print name of U.S. state, U.S. territory, or foreign country.
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
R
AF
9.
COLLEGE OR SOME COLLEGE
T
No, not a U.S. citizen or U.S. national (permanent resident)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Year
Doctorate degree (for example: PhD, EdD)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary school,
home school, and schooling which leads to a high school
diploma or a college degree.
Yes
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
A
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
11830197
Public school or public college
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Yes
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
No
C
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)
19
§,t"¿¤
11.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
D
10.
Person — (continued)
15.
19.
What is this person’s ancestry or ethnic origin?
What was this person’s main reason for moving?
Mark K
J ONE box.
I
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
T
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
e. TRICARE or other military health care
17.
R
AF
f. VA (enrolled for VA health care)
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
Well
Not well
Not at all
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Yes
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
11830205
§,t#&¤
18.
No
D
Very well
a. Is this person deaf or does he/she have serious difficulty
hearing?
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
20
Person — (continued)
26.
How many times has this person been married?
Once
B
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for the next person on
page 25.
Three or more times
27.
22.
In what year did this person last get married?
Year
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
Yes
D
No
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
No
None or
Number of children
c. Does this person have difficulty dressing or bathing?
No
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
T
29.
Yes
Yes
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for the next person on
page 25.
23.
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?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No
24.
No ➜ SKIP to question 30
R
AF
C
Yes
No ➜ SKIP to question 30
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.
What is this person’s marital status?
Less than 6 months
D
Now married
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to D
5 or more years
§,t#.¤
25.
Widowed
In the PAST 12 MONTHS did this person get –
Yes
No
11830213
a. Married?
b. Widowed?
c. Divorced?
21
Person — (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
On active duty in the past, but not now
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
R
AF
Korean War (July 1950 to January 1955)
January 1947 to June 1950
T
31.
35.
World War II (December 1941 to December 1946)
November 1941 or earlier
32.
a. Does this person have a VA service-connected
disability rating?
Other method
E
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
Yes (such as 0%, 10%, 20%, ..., 100%)
36.
b. What is this person’s service-connected disability rating?
0 percent
D
10 or 20 percent
30 or 40 percent
§,t#6¤
33.
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
37.
50 or 60 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
70 percent or higher
Hour
Minute
:
a. LAST WEEK, did this person work for pay at a job
(or business)?
38.
a.m.
p.m.
Yes ➜ SKIP to question 34
How many minutes did it usually take this person to get
from home to work LAST WEEK?
No – Did not work (or retired)
Minutes
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
22
11830221
No ➜ SKIP to question 33a
Person — (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
F
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
G
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
45.
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
R
AF
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Yes, could have gone to work
Federal government civilian employee
No, because of own temporary illness
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice,
or farm
D
42.
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to G
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
11830239
No ➜ SKIP to G
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
23
§,t#H¤
40.
T
Yes ➜ SKIP to question 41
No
DESCRIPTION OF EMPLOYMENT
Person — (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
T
TOTAL AMOUNT – Dollars
$
.00
46.
INCOME IN 2019
R
AF
No
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. 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. Mark K
J the "No"
I
box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before deductions
for taxes, bonds, dues, or other items?
D
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
.00
No
OR
Loss
None
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
No
What was this person’s total income for 2019?
.00
Loss
24
$
.00
TOTAL AMOUNT for 2019
Loss
11830247
§,t#P¤
No
.00
No
Person —
12.
Please copy the name of the Person listed on page 5, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Last Name(s)
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
8.
Is this person a citizen or national of the United States?
Grade 1 through 11 – Specify grade 1 – 11
C
Yes, born in American Samoa ➜ SKIP to question 11a
Yes, born in another U.S. state or U.S. territory
12th grade – NO DIPLOMA
Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
No, not a U.S. citizen or U.S. national (temporary resident)
Where was this person born?
Print name of U.S. state, U.S. territory, or foreign country.
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
R
AF
9.
COLLEGE OR SOME COLLEGE
T
No, not a U.S. citizen or U.S. national (permanent resident)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Year
Doctorate degree (for example: PhD, EdD)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary school,
home school, and schooling which leads to a high school
diploma or a college degree.
Yes
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
A
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
11830254
Public school or public college
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Yes
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
No
C
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)
25
§,t#W¤
11.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
D
10.
Person — (continued)
15.
19.
What is this person’s ancestry or ethnic origin?
What was this person’s main reason for moving?
Mark K
J ONE box.
I
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
T
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
e. TRICARE or other military health care
17.
R
AF
f. VA (enrolled for VA health care)
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
Well
Not well
Not at all
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Yes
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
11830262
§,t#_¤
18.
No
D
Very well
a. Is this person deaf or does he/she have serious difficulty
hearing?
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
26
Person — (continued)
26.
How many times has this person been married?
Once
B
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for the next person on
page 31.
Three or more times
27.
22.
In what year did this person last get married?
Year
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
Yes
D
No
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
No
None or
Number of children
c. Does this person have difficulty dressing or bathing?
No
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
T
29.
Yes
Yes
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for the next person on
page 31.
23.
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?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No
24.
No ➜ SKIP to question 30
R
AF
C
Yes
No ➜ SKIP to question 30
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.
What is this person’s marital status?
Less than 6 months
D
Now married
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to D
5 or more years
§,t#g¤
25.
Widowed
In the PAST 12 MONTHS did this person get –
Yes
No
11830270
a. Married?
b. Widowed?
c. Divorced?
27
Person — (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
On active duty in the past, but not now
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
R
AF
Korean War (July 1950 to January 1955)
January 1947 to June 1950
T
31.
35.
World War II (December 1941 to December 1946)
November 1941 or earlier
32.
a. Does this person have a VA service-connected
disability rating?
Other method
E
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
Yes (such as 0%, 10%, 20%, ..., 100%)
36.
b. What is this person’s service-connected disability rating?
0 percent
D
10 or 20 percent
30 or 40 percent
§,t#y¤
33.
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
37.
50 or 60 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
70 percent or higher
Hour
Minute
:
a. LAST WEEK, did this person work for pay at a job
(or business)?
38.
a.m.
p.m.
Yes ➜ SKIP to question 34
How many minutes did it usually take this person to get
from home to work LAST WEEK?
No – Did not work (or retired)
Minutes
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
28
11830288
No ➜ SKIP to question 33a
Person — (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
F
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
G
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
45.
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
R
AF
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Yes, could have gone to work
Federal government civilian employee
No, because of own temporary illness
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice,
or farm
D
42.
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to G
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
11830296
No ➜ SKIP to G
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
29
§,t#£¤
40.
T
Yes ➜ SKIP to question 41
No
DESCRIPTION OF EMPLOYMENT
Person — (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
T
TOTAL AMOUNT – Dollars
$
.00
46.
INCOME IN 2019
R
AF
No
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. 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. Mark K
J the "No"
I
box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before deductions
for taxes, bonds, dues, or other items?
D
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
.00
No
OR
Loss
None
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
No
What was this person’s total income for 2019?
.00
Loss
30
$
.00
TOTAL AMOUNT for 2019
Loss
11830304
§,t$%¤
No
.00
No
Person —
12.
Please copy the name of the Person listed on page 6, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Last Name(s)
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
8.
Is this person a citizen or national of the United States?
Grade 1 through 11 – Specify grade 1 – 11
C
Yes, born in American Samoa ➜ SKIP to question 11a
Yes, born in another U.S. state or U.S. territory
12th grade – NO DIPLOMA
Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
No, not a U.S. citizen or U.S. national (temporary resident)
Where was this person born?
Print name of U.S. state, U.S. territory, or foreign country.
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
R
AF
9.
COLLEGE OR SOME COLLEGE
T
No, not a U.S. citizen or U.S. national (permanent resident)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Year
Doctorate degree (for example: PhD, EdD)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary school,
home school, and schooling which leads to a high school
diploma or a college degree.
Yes
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
A
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
11830312
Public school or public college
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Yes
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
No
C
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)
31
§,t$-¤
11.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
D
10.
Person — (continued)
15.
19.
What is this person’s ancestry or ethnic origin?
What was this person’s main reason for moving?
Mark K
J ONE box.
I
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
T
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
e. TRICARE or other military health care
17.
R
AF
f. VA (enrolled for VA health care)
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
Well
Not well
Not at all
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Yes
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
11830320
§,t$5¤
18.
No
D
Very well
a. Is this person deaf or does he/she have serious difficulty
hearing?
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
32
Person — (continued)
26.
How many times has this person been married?
Once
Two times
B
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, skip to the questions for the next person on page 7
of an additional D-CQ-AS. If this is the last person, SKIP to
page 44 of the D-Q-AS.
Three or more times
27.
In what year did this person last get married?
Year
22.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
Yes
D
No
b. Does this person have serious difficulty walking or
climbing stairs?
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or
No
29.
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
T
c. Does this person have difficulty dressing or bathing?
Number of children
Yes
Yes
No
C
R
AF
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, skip to the questions for the next person on page 7
of an additional D-CQ-AS. If this is the last person, SKIP to
page 44 of the D-Q-AS.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Yes
23.
No ➜ SKIP to question 30
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
24.
Less than 6 months
D
No
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.
What is this person’s marital status?
6 to 11 months
Now married
1 or 2 years
Widowed
3 or 4 years
Divorced
5 or more years
§,t$G¤
Separated
Never married ➜ SKIP to D
11830338
25.
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
33
Person — (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
On active duty in the past, but not now
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
R
AF
Korean War (July 1950 to January 1955)
January 1947 to June 1950
T
31.
35.
World War II (December 1941 to December 1946)
November 1941 or earlier
32.
a. Does this person have a VA service-connected
disability rating?
Other method
E
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
Yes (such as 0%, 10%, 20%, ..., 100%)
36.
b. What is this person’s service-connected disability rating?
0 percent
D
10 or 20 percent
30 or 40 percent
§,t$O¤
33.
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
37.
50 or 60 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
70 percent or higher
Hour
Minute
:
a. LAST WEEK, did this person work for pay at a job
(or business)?
38.
a.m.
p.m.
Yes ➜ SKIP to question 34
How many minutes did it usually take this person to get
from home to work LAST WEEK?
No – Did not work (or retired)
Minutes
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
34
11830346
No ➜ SKIP to question 33a
Person — (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
F
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
G
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
45.
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
R
AF
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Yes, could have gone to work
Federal government civilian employee
No, because of own temporary illness
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice,
or farm
D
42.
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to G
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
11830353
No ➜ SKIP to G
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
35
§,t$V¤
40.
T
Yes ➜ SKIP to question 41
No
DESCRIPTION OF EMPLOYMENT
Person — (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
T
TOTAL AMOUNT – Dollars
$
.00
46.
INCOME IN 2019
R
AF
No
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. 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. Mark K
J the "No"
I
box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before deductions
for taxes, bonds, dues, or other items?
D
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for the next person on
page 7 of an additional D-CQ-AS. If this is the last
person, SKIP to page 44 of the D-Q-AS.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
36
11830361
§,t$^¤
No
.00
No
| File Type | application/pdf |
| File Modified | 2018-11-26 |
| File Created | 2018-11-21 |