D-Q-MI CNMI Enumerator Questionnaire

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
TM

2020 Census of the Commonwealth
of the Northern Mariana Islands

Commonwealth of the
Northern Mariana Islands

Census Office

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

County
FOR NPC
USE ONLY

BCU

Map Spot

Within Map Spot ID

➤

➤

APPLY LABEL HERE

Are there any continuation questionnaires for this address?
Yes ➜ Number of continuation questionnaires =
No

Apt/Unit (For example: Apt A or Lot 3)

T

Address Number (For example: 5007)

R
AF

Street or Road Name (For example: N Maple Ave)

Physical Description (if applicable)

Village/Municipality/Estate

Start here

ZIP Code

Did you or anyone in this household live or stay here on
April 1, 2020?
Yes

1.

No ➜ Skip to S3.

11960010

S2.

Number of people =
Does someone usually live at this
[house/apartment/mobile home], or is this a vacation or
seasonal home where no one usually lives?
Usually lives here – Skip to question 1.
Vacation or seasonal home or held for occasional use – Skip
to page 7.

S3.

We need to count people where they live and sleep most of
the time. Please read the WHO TO COUNT section on the
Flashcard. Based on these instructions, how many
people were living or staying in this
[house/apartment/mobile home] on April 1, 2020?

2.

Were there any additional people staying here on April 1, 2020
that you did not include in the count in the previous question?
For example:
J all that apply. Include any additional people on the
I
Mark K
person pages.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

On April 1, 2020, was this unit
Occupied by a different household? – Using a knowledgeable
respondent, complete this questionnaire for the people occupying
the household on April 1, 2020.

Relatives, such as adult children, cousins, or in-laws

Vacant? – Skip to page 7.

People staying here temporarily

Nonrelatives, such as roommates or live-in babysitters

No additional people

Not a housing unit – Skip to “Respondent Information”
on page 44.
FORM

D-Q-MI (11-19-2018) Draft 10

§,£!+¤

S1.

D

Use a blue or black pen.

Person 1
3.

Now I am going to ask you questions about each person
staying here. If there is someone staying here who pays the
rent or owns this residence, I would like to start by listing
him or her as Person 1. If the owner or the person who pays
the rent is not staying here, I can start by listing any adult
staying here as Person 1.

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

6.

Please read the HISPANIC ORIGIN section on the Flashcard.
Is Person 1 of Hispanic, Latino, or Spanish origin?

What is Person 1’s name?
Print name below and verify the spelling.

No, not of Hispanic, Latino, or Spanish origin

Last Name(s)

Yes, Puerto Rican

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban
First Name

Is Person 1 male or female? Mark K
J ONE box.
I

5.

Female

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

What is Person 1’s age on April 1, 2020? What is Person 1’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

Please read the RACE section on the Flashcard.
What is Person 1’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I

T

Male

7.

R
AF

4.

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

MI

Print numbers in boxes.
Month
Day

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Year of birth

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

§,£!=¤

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

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

Some other race – Print race or origin. C

➜ If more people were counted in question 1 on the front
page, continue with Person 2 on the next page.
Otherwise, skip to page 7.

2

11960028

D

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

1.

What is the name of

Person 2

➜ 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.
Last Name(s)

6.

First Name

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

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

2.

Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
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

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

7.

For another reason
No

In a nursing home

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

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.

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

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

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

D

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

Foster child

Some other race – Print race or origin. C

11960036

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

Print numbers in boxes.
Month
Day

Year of birth

➜ If more people were counted in question 1 on the front
page, continue with Person 3 on the next page.
Otherwise, skip to page 7.

years

3

§,£!E¤

Roommate or housemate

1.

What is the name of

Person 3

➜ 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.
Last Name(s)

6.

First Name

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

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

2.

Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

7.

For another reason

For a job or business

No

In a nursing home

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I

T

3.

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

Opposite-sex husband/wife/spouse

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
Father or mother

D

Grandchild

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

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

Chinese

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

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.

11960044

§,£!M¤

Roommate or housemate

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

Print numbers in boxes.
Month
Day

Year of birth

➜ If more people were counted in question 1 on the front
page, continue with Person 4 on the next page.
Otherwise, skip to page 7.

years

4

1.

What is the name of

Person 4

➜ 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.
Last Name(s)

6.

First Name

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

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

2.

Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
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

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

7.

For another reason
No

In a nursing home

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

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.

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

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

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother

D

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

Foster child

Some other race – Print race or origin. C

11960051

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

Print numbers in boxes.
Month
Day

Year of birth

➜ If more people were counted in question 1 on the front
page, continue with Person 5 on the next page.
Otherwise, skip to page 7.

years

5

§,£!T¤

Roommate or housemate

1.

What is the name of

Person 5

➜ 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.
Last Name(s)

6.

First Name

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

MI

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

2.

Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

7.

For another reason

For a job or business

No

In a nursing home

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I

T

3.

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

Opposite-sex husband/wife/spouse

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
Father or mother

D

Grandchild

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

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

Chinese

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

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.

11960069

§,£!f¤

Roommate or housemate

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

Print numbers in boxes.
Month
Day

➜ If more people were counted in question 1 on the front
page of the D-Q-MI, continue with the next person on
an additional continuation questionnaire (D-CQ-MI)
and update the number of continuation questionnaires
on page 1 of the D-Q-MI.

Year of birth

years

6

Housing

A

Please answer the following questions about this house,
apartment, or mobile home.

1.

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

4.

Less than 1 acre ➜ SKIP to question 6a

Please read the BUILDING TYPE section on the Flashcard.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.

1 to 9.9 acres
10 or more acres

A mobile home

5.

A one-family house detached from any other house
A one-family house attached to one or more houses

$1 to $999

Three or more houses (American Samoa only)

$1,000 to $2,499

A building with 2 apartments

$2,500 to $4,999

A building with 3 or 4 apartments

$5,000 to $9,999

A building with 5 to 9 apartments

$10,000 or more

A building with 10 to 19 apartments

A building with 50 or more apartments

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

R
AF

Boat, RV, van, etc.

6.

T

A building with 20 to 49 apartments

What were the actual sales of all agricultural products from
this property in 2019?
None

Two houses (American Samoa only)

2.

How many acres is this house or mobile home on?

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

Number of rooms

1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959

Number of bedrooms

D

1940 to 1949

b. How many of these rooms are bedrooms? Count as
bedrooms those rooms you would list if this house,
apartment, or mobile home were for sale or rent. If this is
an efficiency/studio apartment, print "0".

1939 or earlier

7.

Does this house, apartment, or mobile home have –

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

Yes

No

a. Running water?

Year

b. A bathtub or shower?

11940079

c. A flush toilet?
d. A sink with a faucet?
e. A stove or range?
f. A refrigerator?

8.

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

7

§,¡!p¤

3.

Housing (continued)
9.

13.

Please read the SOURCE OF WATER section on the Flashcard.
In 2019, did this house, apartment, or mobile home get water
from – Mark K
J all that apply.
I

Please read the COMPUTER USE section on the Flashcard.
At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?
Yes
No

A public system?
A cistern, catchment, tanks, or drums?
A delivery vendor or water truck?

a. Desktop or laptop

A supermarket or grocery store?
Some other source (a standpipe, spring, individual well, etc.)?

b. Smartphone

14.

c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C

Please read the SEWAGE DISPOSAL section on the Flashcard.
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark K
J ONE box.
I
Public sewer
Septic tank or cesspool
Other

10. a. At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?

15.

Yes

Average monthly cost – Dollars

T

No ➜ SKIP to question 12

$

b. Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?

OR

Included in rent or condominium fee
No charge or electricity not used

No ➜ SKIP to question 12

11.

.00

R
AF

Yes

a. What is the average monthly cost of electricity for this
house, apartment, or mobile home?

b. What is the average monthly cost of gas for this house,
apartment, or mobile home?

Please read the INTERNET section on the Flashcard.
Do you or any member of this household have access to the
Internet using a –
Yes
No

Average monthly cost – Dollars

$

a. Cellular data plan for a smartphone or other
mobile device?

.00

OR

b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?

Included in rent or condominium fee

D

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

c. Satellite Internet service installed in this household?
d. Dial-up Internet service installed in this household?

c. What is the average monthly cost of water and sewer for
this house, apartment, or mobile home?

e. Some other service? – Specify service C

Average monthly cost – Dollars

.00
OR

12. How many automobiles, vans, and trucks of one-ton

Included in rent or condominium fee

capacity or less are kept at home for use by members of
this household?

No charge

None

d. What is the average monthly cost of oil, coal, kerosene,
wood, etc., for this house, apartment, or mobile home?

1
2

Average monthly cost – Dollars

3

$

4

.00
OR

5
6 or more

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

8

11960085

§,£!v¤

$

Housing (continued)
C
16.

In 2019, did you or any member of this household receive
benefits from the Food Stamp Program, SNAP (the
Supplemental Nutrition Assistance Program), or NAP
(Nutrition Assistance Program)? Do NOT include WIC, the
School Lunch Program, or assistance from food banks.

Ask questions 20 – 24 if this person or any member of this
household OWNS or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E on the next page.

20.

Yes

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

No

Amount – Dollars

$

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

21.

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

What were the annual real estate taxes on THIS property in
2019?
Annual amount – Dollars

Monthly amount – Dollars

$

.00

$

.00

.00

OR

OR

None

None

Mark K
J ONE box.
I

What was the annual payment for fire, hazard, typhoon or
hurricane, and flood insurance on THIS property in 2019?

Annual amount – Dollars

R
AF

18. Is this house, apartment, or mobile home –

T

22.

No

$

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

OR

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

None

23.

Occupied without payment of rent? ➜ SKIP to C

B

.00

a. Do you or any member of this household have a
mortgage, deed of trust, contract to purchase, or similar
debt on THIS property?
Yes, mortgage, deed of trust, or similar debt

Ask questions 19a and 19b if this house, apartment, or
mobile home is RENTED. Otherwise, SKIP to question 20.

Yes, contract to purchase

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

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

Monthly amount – Dollars

$

Monthly amount – Dollars

.00

$

b. Does the monthly rent include any meals?

OR

Yes

11960093

.00
No regular payment required ➜ SKIP to question 24a

No

c. Does the regular monthly mortgage payment include
payments for real estate taxes on THIS property?
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required

d. Does the regular monthly mortgage payment include
payments for fire, hazard, typhoon or hurricane, or flood
insurance on THIS property?
Yes, insurance included in mortgage payment
No, insurance paid separately or no insurance

9

§,£!~¤

19.

D

No ➜ SKIP to question 24a

Housing (continued)
24.

a. Do you or any member of this household have a second
mortgage or a home equity loan on THIS property?
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home equity loan
No ➜ SKIP to D

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

$

.00
OR

Ask question 25 if this is a MOBILE HOME or a BOAT.
Otherwise, SKIP to E.

25.

What were the total annual costs for installment loan
payments, personal property taxes, site rent, marina fee,
registration fees, and license fees on THIS mobile home or
boat and its site/slip fee in 2019? Exclude real estate taxes.
Annual costs – Dollars

$

.00

Ask questions about PERSON 1 on the next page if you listed
at least one person on page 2. Otherwise, SKIP to page 44
for further instructions.

11960101

§,£""¤

D

E

R
AF

D

T

No regular payment required

10

Person 1

12.

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

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
No schooling completed

First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool or pre-kindergarten

8.

Kindergarten

Please read the CITIZEN or NATIONAL section on the
Flashcard.
Is this person a citizen or national of the United States?

Grade 1 through 11 – Specify grade 1 – 11

Yes, born in the Commonwealth of the
Northern Mariana Islands ➜ SKIP to question 11a

C

12th grade – NO DIPLOMA

Yes, born in another U.S. state or U.S. territory

HIGH SCHOOL GRADUATE

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

Regular high school diploma
GED or alternative credential

No, not a U.S. citizen or U.S. national (permanent resident)
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.

T

COLLEGE OR SOME COLLEGE

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

AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

When did this person come to live in the Commonwealth
of the Northern Mariana Islands?
If this person came to live in the Commonwealth of the
Northern Mariana Islands more than once, print latest year.
Year

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

F

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

D

11.

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

11960119

b. Was that a public school or college, a private school or
college, or home school?
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

No

Grade 1 through 12 – Specify grade 1 – 12

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)

11

§,£"4¤

10.

Person 1 (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

Commonwealth of the Northern Mariana Islands

No

a. Insurance through a current or former employer
or union (of this person or another family member)

Outside the Commonwealth of the Northern Mariana Islands –
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

Commonwealth of the Northern Mariana Islands
Outside the Commonwealth of the Northern Mariana Islands –
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

11960127

§,£"<¤

18.

No

D

Very well

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

No, different house in the Commonwealth of the
Northern Mariana Islands
No, outside the Commonwealth of the Northern Mariana Islands –
Print name of U.S. state, U.S. territory, or foreign country below. C

12

Person 1 (continued)

26.

How many times has this person been married?
Once
Two times

G

Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 2 on page 17.

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
No

I

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
No

None or

c. Does this person have difficulty dressing or bathing?

No

Number of children

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

How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.

Yes

Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 2 on page 17.

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

H

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
Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➜ SKIP to I

In the PAST 12 MONTHS did this person get –
Yes

§,£"D¤

25.

5 or more years

No

11960135

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

13

Person 1 (continued)
30.

34.

At what location did this person work LAST WEEK?
Commonwealth of the Northern Mariana Islands –
Print name of village below. C

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 the Commonwealth of the Northern Mariana Islands –
Print the 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

35.

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.

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

T

31.

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.

Plane or seaplane

February 1955 to July 1964

Boat, ferry, or water taxi

Korean War (July 1950 to January 1955)

Worked from home ➜ SKIP to question 43a

R
AF

January 1947 to June 1950

Other method

World War II (December 1941 to December 1946)
November 1941 or earlier

32.

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

J

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.

Person(s)

b. What is this person’s service-connected disability rating?
0 percent

D

10 or 20 percent
30 or 40 percent

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

37.

50 or 60 percent

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

70 percent or higher

Minute

:

§,£"L¤

33.

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

14

11960143

No ➜ SKIP to question 33a

Person 1 (continued)

44.

During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK

K

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?

L

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 L

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

11960150

No ➜ SKIP to L

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

15

§,£"S¤

40.

T

Yes ➜ SKIP to question 41
No

DESCRIPTION OF EMPLOYMENT

Person 1 (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 Person 2 on the next
page. If no one is listed as Person 2 on page 3, SKIP
to page 44 for further instructions.

TOTAL AMOUNT – Dollars

$
No

.00
Loss

16

11960168

§,£"e¤

No

.00

No

Person 2

12.

Please copy the name of Person 2 from page 3, then continue
answering questions below.
Last Name(s)

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
No schooling completed

First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool or pre-kindergarten

8.

Kindergarten

Please read the CITIZEN or NATIONAL section on the
Flashcard.
Is this person a citizen or national of the United States?

Grade 1 through 11 – Specify grade 1 – 11

Yes, born in the Commonwealth of the
Northern Mariana Islands ➜ SKIP to question 11a

C

12th grade – NO DIPLOMA

Yes, born in another U.S. state or U.S. territory

HIGH SCHOOL GRADUATE

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

Regular high school diploma
GED or alternative credential

No, not a U.S. citizen or U.S. national (permanent resident)
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.

T

COLLEGE OR SOME COLLEGE

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

AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

When did this person come to live in the Commonwealth
of the Northern Mariana Islands?
If this person came to live in the Commonwealth of the
Northern Mariana Islands more than once, print latest year.
Year

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

F

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

D

11.

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

11960176

b. Was that a public school or college, a private school or
college, or home school?
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

No

Grade 1 through 12 – Specify grade 1 – 12

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)

17

§,£"m¤

10.

Person 2 (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

Commonwealth of the Northern Mariana Islands

No

a. Insurance through a current or former employer
or union (of this person or another family member)

Outside the Commonwealth of the Northern Mariana Islands –
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

Commonwealth of the Northern Mariana Islands
Outside the Commonwealth of the Northern Mariana Islands –
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

11960184

§,£"u¤

18.

No

D

Very well

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

No, different house in the Commonwealth of the
Northern Mariana Islands
No, outside the Commonwealth of the Northern Mariana Islands –
Print name of U.S. state, U.S. territory, or foreign country below. C

18

Person 2 (continued)

26.

How many times has this person been married?
Once
Two times

G

Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 3 on page 23.

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
No

I

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
No

None or

c. Does this person have difficulty dressing or bathing?

No

Number of children

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

How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.

Yes

Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 3 on page 23.

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

H

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
Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➜ SKIP to I

In the PAST 12 MONTHS did this person get –
Yes

§,£"}¤

25.

5 or more years

No

11960192

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

19

Person 2 (continued)
30.

34.

At what location did this person work LAST WEEK?
Commonwealth of the Northern Mariana Islands –
Print name of village below. C

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 the Commonwealth of the Northern Mariana Islands –
Print the 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

35.

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.

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

T

31.

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.

Plane or seaplane

February 1955 to July 1964

Boat, ferry, or water taxi

Korean War (July 1950 to January 1955)

Worked from home ➜ SKIP to question 43a

R
AF

January 1947 to June 1950

Other method

World War II (December 1941 to December 1946)
November 1941 or earlier

32.

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

J

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.

Person(s)

b. What is this person’s service-connected disability rating?
0 percent

D

10 or 20 percent
30 or 40 percent

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

37.

50 or 60 percent

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

70 percent or higher

Minute

:

§,£#!¤

33.

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

20

11960200

No ➜ SKIP to question 33a

Person 2 (continued)

44.

During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK

K

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?

L

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 L

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

11960218

No ➜ SKIP to L

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

21

§,£#3¤

40.

T

Yes ➜ SKIP to question 41
No

DESCRIPTION OF EMPLOYMENT

Person 2 (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 Person 3 on the next
page. If no one is listed as Person 3 on page 4, SKIP
to page 44 for further instructions.

TOTAL AMOUNT – Dollars

$
No

.00
Loss

22

11960226

§,£#;¤

No

.00

No

Person 3

12.

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

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
No schooling completed

First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool or pre-kindergarten

8.

Kindergarten

Please read the CITIZEN or NATIONAL section on the
Flashcard.
Is this person a citizen or national of the United States?

Grade 1 through 11 – Specify grade 1 – 11

Yes, born in the Commonwealth of the
Northern Mariana Islands ➜ SKIP to question 11a

C

12th grade – NO DIPLOMA

Yes, born in another U.S. state or U.S. territory

HIGH SCHOOL GRADUATE

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

Regular high school diploma
GED or alternative credential

No, not a U.S. citizen or U.S. national (permanent resident)
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.

T

COLLEGE OR SOME COLLEGE

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

AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

When did this person come to live in the Commonwealth
of the Northern Mariana Islands?
If this person came to live in the Commonwealth of the
Northern Mariana Islands more than once, print latest year.
Year

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

F

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

D

11.

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

11960234

b. Was that a public school or college, a private school or
college, or home school?
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

No

Grade 1 through 12 – Specify grade 1 – 12

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)

23

§,£#C¤

10.

Person 3 (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

Commonwealth of the Northern Mariana Islands

No

a. Insurance through a current or former employer
or union (of this person or another family member)

Outside the Commonwealth of the Northern Mariana Islands –
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

Commonwealth of the Northern Mariana Islands
Outside the Commonwealth of the Northern Mariana Islands –
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

11960242

§,£#K¤

18.

No

D

Very well

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

No, different house in the Commonwealth of the
Northern Mariana Islands
No, outside the Commonwealth of the Northern Mariana Islands –
Print name of U.S. state, U.S. territory, or foreign country below. C

24

Person 3 (continued)

26.

How many times has this person been married?
Once
Two times

G

Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 4 on page 29.

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
No

I

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
No

None or

c. Does this person have difficulty dressing or bathing?

No

Number of children

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

How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.

Yes

Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 4 on page 29.

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

H

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
Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➜ SKIP to I

In the PAST 12 MONTHS did this person get –
Yes

§,£#\¤

25.

5 or more years

No

11960259

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

25

Person 3 (continued)
30.

34.

At what location did this person work LAST WEEK?
Commonwealth of the Northern Mariana Islands –
Print name of village below. C

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 the Commonwealth of the Northern Mariana Islands –
Print the 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

35.

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.

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

T

31.

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.

Plane or seaplane

February 1955 to July 1964

Boat, ferry, or water taxi

Korean War (July 1950 to January 1955)

Worked from home ➜ SKIP to question 43a

R
AF

January 1947 to June 1950

Other method

World War II (December 1941 to December 1946)
November 1941 or earlier

32.

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

J

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.

Person(s)

b. What is this person’s service-connected disability rating?
0 percent

D

10 or 20 percent
30 or 40 percent

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

37.

50 or 60 percent

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

70 percent or higher

Minute

:

§,£#d¤

33.

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

26

11960267

No ➜ SKIP to question 33a

Person 3 (continued)

44.

During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK

K

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?

L

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 L

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

11960275

No ➜ SKIP to L

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

27

§,£#l¤

40.

T

Yes ➜ SKIP to question 41
No

DESCRIPTION OF EMPLOYMENT

Person 3 (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 Person 4 on the next
page. If no one is listed as Person 4 on page 5, SKIP
to page 44 for further instructions.

TOTAL AMOUNT – Dollars

$
No

.00
Loss

28

11960283

§,£#t¤

No

.00

No

Person 4

12.

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

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
No schooling completed

First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool or pre-kindergarten

8.

Kindergarten

Please read the CITIZEN or NATIONAL section on the
Flashcard.
Is this person a citizen or national of the United States?

Grade 1 through 11 – Specify grade 1 – 11

Yes, born in the Commonwealth of the
Northern Mariana Islands ➜ SKIP to question 11a

C

12th grade – NO DIPLOMA

Yes, born in another U.S. state or U.S. territory

HIGH SCHOOL GRADUATE

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

Regular high school diploma
GED or alternative credential

No, not a U.S. citizen or U.S. national (permanent resident)
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.

T

COLLEGE OR SOME COLLEGE

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

AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

When did this person come to live in the Commonwealth
of the Northern Mariana Islands?
If this person came to live in the Commonwealth of the
Northern Mariana Islands more than once, print latest year.
Year

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

F

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

D

11.

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

11960291

b. Was that a public school or college, a private school or
college, or home school?
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

No

Grade 1 through 12 – Specify grade 1 – 12

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)

29

§,£#|¤

10.

Person 4 (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

Commonwealth of the Northern Mariana Islands

No

a. Insurance through a current or former employer
or union (of this person or another family member)

Outside the Commonwealth of the Northern Mariana Islands –
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

Commonwealth of the Northern Mariana Islands
Outside the Commonwealth of the Northern Mariana Islands –
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

11960309

§,£$*¤

18.

No

D

Very well

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

No, different house in the Commonwealth of the
Northern Mariana Islands
No, outside the Commonwealth of the Northern Mariana Islands –
Print name of U.S. state, U.S. territory, or foreign country below. C

30

Person 4 (continued)

26.

How many times has this person been married?
Once
Two times

G

Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 5 on page 35.

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
No

I

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
No

None or

c. Does this person have difficulty dressing or bathing?

No

Number of children

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

How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.

Yes

Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 5 on page 35.

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

H

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
Widowed

6 to 11 months

Divorced

1 or 2 years

Separated

3 or 4 years

Never married ➜ SKIP to I

In the PAST 12 MONTHS did this person get –
Yes

§,£$2¤

25.

5 or more years

No

11960317

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

31

Person 4 (continued)
30.

34.

At what location did this person work LAST WEEK?
Commonwealth of the Northern Mariana Islands –
Print name of village below. C

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 the Commonwealth of the Northern Mariana Islands –
Print the 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

35.

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.

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

T

31.

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.

Plane or seaplane

February 1955 to July 1964

Boat, ferry, or water taxi

Korean War (July 1950 to January 1955)

Worked from home ➜ SKIP to question 43a

R
AF

January 1947 to June 1950

Other method

World War II (December 1941 to December 1946)
November 1941 or earlier

32.

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

J

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.

Person(s)

b. What is this person’s service-connected disability rating?
0 percent

D

10 or 20 percent
30 or 40 percent

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

37.

50 or 60 percent

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

70 percent or higher

Minute

:

§,£$:¤

33.

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

32

11960325

No ➜ SKIP to question 33a

Person 4 (continued)

44.

During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK

K

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?

L

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 L

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

11960333

No ➜ SKIP to L

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

33

§,£$B¤

40.

T

Yes ➜ SKIP to question 41
No

DESCRIPTION OF EMPLOYMENT

Person 4 (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 Person 5 on the next
page. If no one is listed as Person 5 on page 6, SKIP
to page 44 for further instructions.

TOTAL AMOUNT – Dollars

$
No

.00
Loss

34

11960341

§,£$J¤

No

.00

No

Person 5

12.

Please copy the name of Person 5 from page 6, then continue
answering questions below.
Last Name(s)

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
No schooling completed

First Name

MI

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool or pre-kindergarten

8.

Kindergarten

Please read the CITIZEN or NATIONAL section on the
Flashcard.
Is this person a citizen or national of the United States?

Grade 1 through 11 – Specify grade 1 – 11

Yes, born in the Commonwealth of the
Northern Mariana Islands ➜ SKIP to question 11a

C

12th grade – NO DIPLOMA

Yes, born in another U.S. state or U.S. territory

HIGH SCHOOL GRADUATE

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

Regular high school diploma
GED or alternative credential

No, not a U.S. citizen or U.S. national (permanent resident)
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.

T

COLLEGE OR SOME COLLEGE

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

AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

When did this person come to live in the Commonwealth
of the Northern Mariana Islands?
If this person came to live in the Commonwealth of the
Northern Mariana Islands more than once, print latest year.
Year

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

F

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

D

11.

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

11960358

b. Was that a public school or college, a private school or
college, or home school?
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

No

Grade 1 through 12 – Specify grade 1 – 12

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)

35

§,£$[¤

10.

Person 5 (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

Commonwealth of the Northern Mariana Islands

No

a. Insurance through a current or former employer
or union (of this person or another family member)

Outside the Commonwealth of the Northern Mariana Islands –
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

Commonwealth of the Northern Mariana Islands
Outside the Commonwealth of the Northern Mariana Islands –
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

11960366

§,£$c¤

18.

No

D

Very well

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

No, different house in the Commonwealth of the
Northern Mariana Islands
No, outside the Commonwealth of the Northern Mariana Islands –
Print name of U.S. state, U.S. territory, or foreign country below. C

36

Person 5 (continued)

26.

How many times has this person been married?
Once
Two times

G

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 the D-CQ-MI. If this is the last person, SKIP to page 44.

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

I

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
No

How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or

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
No

Yes

H

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 the D-CQ-MI. If this is the last person, SKIP to page 44.

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.

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

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

24.

No ➜ SKIP to question 30

Now married

6 to 11 months

Widowed

1 or 2 years

Divorced

3 or 4 years

Separated

5 or more years

11960374

25.

§,£$k¤

Never married ➜ SKIP to I

In the PAST 12 MONTHS did this person get –
Yes

No

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

37

Person 5 (continued)
30.

34.

At what location did this person work LAST WEEK?
Commonwealth of the Northern Mariana Islands –
Print name of village below. C

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 the Commonwealth of the Northern Mariana Islands –
Print the 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

35.

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.

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

T

31.

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.

Plane or seaplane

February 1955 to July 1964

Boat, ferry, or water taxi

Korean War (July 1950 to January 1955)

Worked from home ➜ SKIP to question 43a

R
AF

January 1947 to June 1950

Other method

World War II (December 1941 to December 1946)
November 1941 or earlier

32.

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

J

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.

Person(s)

b. What is this person’s service-connected disability rating?
0 percent

D

10 or 20 percent
30 or 40 percent

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

37.

50 or 60 percent

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

70 percent or higher

Minute

:

§,£$s¤

33.

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

38

11960382

No ➜ SKIP to question 33a

Person 5 (continued)

44.

During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK

K

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?

L

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 L

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

11960390

No ➜ SKIP to L

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

39

§,£${¤

40.

T

Yes ➜ SKIP to question 41
No

DESCRIPTION OF EMPLOYMENT

Person 5 (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 the D-CQ-MI. If this is the last person,
SKIP to page 44.

TOTAL AMOUNT – Dollars

$
No

.00
Loss

40

11960408

§,£%)¤

No

.00

No

T
R
AF
11960416

§,£%1¤

D

This page intentionally left blank.

41

T
R
AF

11960424

§,£%9¤

D

This page intentionally left blank.

42

T
R
AF
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval
number xxxx-xxxx confirms this approval. If this number were not displayed, we could not conduct the census.

43

§,£%A¤

D
11960432

The U.S. Census Bureau estimates that completing the questionnaire will take 40 minutes on average. Send comments regarding this
burden estimate or any other aspect of this burden to: Paperwork Reduction Project xxxx-xxxx, U.S. Census Bureau, DCMD-2H174,
4600 Silver Hill Road, Washington, DC 20233. You may email comments to <[email protected]>. Use “Paperwork
Reduction Project xxxx-xxxx” as the subject.

RESPONDENT INFORMATION

R1. What is your name? Print name below and verify the spelling.

R2. What is your telephone number? We will only contact
you if needed for official Census Bureau business.

Last Name(s)

Telephone Number
–
First Name

–

MI

R3. To confirm: Did you
Live or stay in this [house/apartment/mobile home]
on April 1, 2020?

Address of proxy

Move in to this [house/apartment/mobile home]
after April 1, 2020?
Not live or stay in this [house/apartment/mobile home]
(neighbor or other proxy)?

FOR OFFICIAL USE ONLY
INTERVIEW SUMMARY

B.

Unit Status on April 1, 2020
Occupied
Vacant – regular

For rent

Vacant – usual home elsewhere

Sold, not occupied

R
AF

Unable to Locate

D.

For sale only

Empty mobile home/trailer site

For seasonal, recreational or
occasional use

Duplicate – record survivor ID below. C

Number of people
listed on questionnaire(s) =
01 – 99 = Total people
00 = Vacant

Rented, not occupied

Uninhabitable/demolished/burned out
Nonresidential

C.

If vacant, ask: Which category best
describes this vacant unit as of
April 1, 2020?

T

A.

For migrant workers
Other vacant

JIC2

JIC1

Interview Outcome Code
UHE

VDC

CO

MOV

REF

REP

PI
OUTCOME CODES:
UHE = Usual Home Elsewhere
MOV= Moved in After April 1
PI = Partial Interview
VDC = Vacant Delete Check

REF = Refusal
CO = Count Only
REP = Replacement

RECORD OF CONTACT

In-Person

DD

/

HH

MM

Outcome

Type

a.m.

:

In-Person

p.m.

MM
In-Person

DD

/

MM

MM
In-Person

DD

/

HH

MM

:

Telephone

OUTCOME CODES: NV = Left Notice of Visit

MM
a.m.

:
DD

HH

/

MM

p.m.
MM

In-Person

p.m.

Telephone

RE = Refusal

DD

HH

/

CI = Conducted Interview

CERTIFICATION

Outcome
a.m.

:

Telephone

a.m.

Outcome

p.m.

In-Person

Outcome

NC = No Contact

HH

/

MM

a.m.

:

DD

Telephone
Outcome

p.m.

Telephone

§,£%I¤

HH

MM

MM

Outcome
a.m.

:

p.m.

11960440

✗

MM

D

Type

OT = Other

CL Initials

I certify that the entries I have made on this questionnaire are true
and correct to the best of my knowledge.
Enumerator’s Signature

Month

Employee ID

Day

CLD Number

Month

44

Day