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pdfOMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
TM
2020 Census of American Samoa Individual Census Questionnaire
American Samoa
FOR NPC
USE ONLY
This is your Individual Census Questionnaire for the 2020 Census of American Samoa. It is important that
everyone be counted, regardless of where they may be living at the time of the census. This Individual Census
Questionnaire is to be used to count people who were living, staying or receiving services in group quarters on
April 1, 2020. Some examples of group quarters include college or university residence halls, nursing homes,
group homes, residential treatment centers, workers’ group living quarters and correctional facilities. Please
answer ALL of the questions on this questionnaire. Then follow the instructions you were given when
you received this questionnaire in order to return it to the appropriate person. You are required by law to
respond to the census (Title 13, U.S. Code, Sections 141, 193, 221 and 223).
BCU
Map Spot
11810017
D
UHE BCU
UHE Map Spot
Within Map Spot ID
UHE Within Map Spot ID
FOR OFFICIAL USE ONLY
The Census Bureau estimates that completing the
questionnaire will take 25 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.
Group Quarters ID
A. PN
This collection of information has been approved by the
Office of Management and Budget (OMB). The eight-digit
approval number that appears at the upper right of the
questionnaire confirms this approval. If this number were
not displayed, we could not conduct the census.
B. Answered By:
C. QC:
D. JIC1
FORM
Respondent
Group Quarters
Administrator
Observation
(TNSOLs only)
Other
Rework
JIC2
D-Q-GE-AS (11-20-2018) Draft 17
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County
R
AF
Census Office
T
Please turn to page 2 to begin.
Use a blue or black pen.
Start here
1.
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origin is not a race.
What is your name? Print name below.
6.
Last Name(s)
Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
MI
Yes, Puerto Rican
Yes, Cuban
2.
Do you live or stay here most of the time?
Yes
3.
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
No
Besides here, what is the full address of a place
where you sometimes live or stay?
7.
I never stay at any other place. I only live here.
What is your race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
T
Address Number (For example: 5007)
Street Name (For example: N Maple Ave)
R
AF
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Apt/Unit (For example: Apt A or Lot 3)
Physical Description (if applicable)
D
Village/Municipality/Estate
ZIP Code
5.
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Are you male or female? Mark K
J ONE box.
I
Male
Chinese
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
Female
What is your age on April 1, 2020, and what is your date of
birth? If you don’t know the exact age, please estimate. For
babies less than 1 year old, do not write the age in months.
Write 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
11810025
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4.
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
Year of birth
years
2
8.
12.
Yes, born in American Samoa ➜ SKIP to question 11a
What is the highest degree or level of school you have
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Yes, born in another U.S. state or U.S. territory
NO SCHOOLING COMPLETED
Are you a citizen or national of the United States?
Yes, born abroad of U.S. citizen or U.S. national parent or parents
No schooling completed
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten
Kindergarten
No, not a U.S. citizen or U.S. national (permanent resident)
Grade 1 through 11 – Specify grade 1 – 11
C
No, not a U.S. citizen or U.S. national (temporary resident)
9.
Where were you born?
Print name of U.S. state, U.S. territory, or foreign country.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
When did you come to live in American Samoa?
If you came to live in American Samoa more than once,
print latest year.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
Year
T
10.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
a. At any time since February 1, 2020, have you 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.
Bachelor’s degree (for example: BA, BS)
R
AF
11.
Yes
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
No ➜ SKIP to question 12
b. Was that a public school or college, a private school or
college, or home school?
A
Answer question 13 if you have a bachelor’s degree or higher.
Otherwise, SKIP to question 14.
Public school or public college
D
Private school or private college or home school
13.
This question focuses on your BACHELOR’S DEGREE.
What was the specific major or majors of any BACHELOR’S
DEGREES you have received? (For example: chemical
engineering, elementary teacher education, organizational
psychology)
14.
Have you 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.
c. What grade or level were you attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
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)
Yes
No
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Grade 1 through 12 – Specify grade 1 – 12
15.
20.
What is your ancestry or ethnic origin?
Yes
(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.
In 2019, did you 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.
No
21.
a. Where was your mother born?
Are you CURRENTLY covered by any of the following types
of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
American Samoa
No
a. Insurance through a current or former employer
or union (of yours or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by you or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was your father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
T
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
a. Do you speak a language other than English at home?
g. Indian Health Service
Yes
R
AF
17.
h. Any other type of health insurance or health
coverage plan – Specify C
No ➜ SKIP to question 18
b. What is this language?
22.
For example: Korean, Italian, Spanish, Vietnamese.
Yes
c. How well do you speak English?
Well
Not well
Not at all
18.
No
b. Are you blind or do you have serious difficulty seeing
even when wearing glasses?
D
Very well
a. Are you deaf or do you have serious difficulty hearing?
Yes
No
Did you live at this address 5 years ago (on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
No, different address in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
19.
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Yes, this address ➜ SKIP to question 20
What was your main reason for moving?
Mark K
J ONE box.
I
Employment
To attend school
Military
Family-related
Housing
Natural disaster
Other reason
4
B
Answer questions 23a – c if you are 5 years old or over.
Otherwise, the questionnaire is complete.
23.
D
Answer question 29 if you are female and 15 years old or over.
Otherwise, SKIP to question 30a.
29.
a. Because of a physical, mental, or emotional condition,
do you have serious difficulty concentrating,
remembering, or making decisions?
None or
Yes
No
30.
b. Do you have serious difficulty walking or climbing
stairs?
b. Are you currently responsible for most of the basic
needs of any grandchildren under the age of 18 who
live in this place?
c. Do you have difficulty dressing or bathing?
Yes
Yes
No
No ➜ SKIP to question 31
T
c. How long have you been responsible for these
grandchildren? If you are financially responsible for more
than one grandchild, answer the question for the grandchild
for whom you have been responsible for the longest period
of time.
R
AF
Answer question 24 if you are 15 years old or over. Otherwise,
the questionnaire is complete.
Because of a physical, mental, or emotional condition, do
you have difficulty doing errands alone such as visiting a
doctor’s office or shopping?
Less than 6 months
6 to 11 months
1 or 2 years
Yes
3 or 4 years
No
25.
a. Do you have any of your own grandchildren under the
age of 18 living in this place?
No ➜ SKIP to question 31
No
24.
Number of children
Yes
Yes
C
How many babies have you ever had, not counting stillbirths?
Do not count stepchildren or children you have adopted.
5 or more years
What is your marital status?
Now married
Widowed
D
Divorced
Separated
Never married ➜ SKIP to D
26.
In the PAST 12 MONTHS did you get –
Yes
No
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a. Married?
11810058
b. Widowed?
c. Divorced?
27.
How many times have you been married?
Once
Two times
Three or more times
28.
In what year did you last get married?
Year
5
31.
35.
Have you ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
At what location did you work LAST WEEK?
American Samoa – Print name of village below. C
Never served in the military ➜ SKIP to question 34a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 33a
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Now on active duty
On active duty in the past, but not now
36.
When did you serve on active duty in the U.S. Armed Forces?
Mark K
J a box for EACH period in which you served, even if just
I
for part of the period.
How did you usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
September 2001 or later
Car, truck, or private van/bus
August 1990 to August 2001 (including Persian Gulf War)
Public van/bus
May 1975 to July 1990
Taxicab
Vietnam Era (August 1964 to April 1975)
Motorcycle
February 1955 to July 1964
Bicycle
Korean War (July 1950 to January 1955)
Walked
January 1947 to June 1950
Plane or seaplane
World War II (December 1941 to December 1946)
Boat, ferry, or water taxi
T
32.
Worked from home ➜ SKIP to question 44a
November 1941 or earlier
Other method
a. Do you have a VA service-connected disability rating?
R
AF
33.
Yes (such as 0%, 10%, 20%, ..., 100%)
E
No ➜ SKIP to question 34a
Answer question 37 if you marked "Car, truck, or private
van/bus" in question 36. Otherwise, SKIP to question 38.
b. What is your service-connected disability rating?
37.
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
34.
Person(s)
38.
D
70 percent or higher
How many people, including you, usually rode to work in the
car, truck, or private van/bus LAST WEEK?
LAST WEEK, what time did your trip to work usually begin?
Hour
a. LAST WEEK, did you work for pay at a job (or
business)?
Minute
:
a.m.
p.m.
Yes ➜ SKIP to question 35
39.
b. LAST WEEK, did you do ANY work for pay, even for
as little as one hour?
How many minutes did it usually take you to get from home
to work LAST WEEK?
Minutes
Yes
No ➜ SKIP to question 40a
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No – Did not work (or retired)
6
F
45.
Answer questions 40 – 43a if you did NOT work last week.
Otherwise, SKIP to question 43b.
40.
During 2019, in the WEEKS WORKED, how many hours did
you usually work each WEEK?
Usual hours worked each WEEK
a. LAST WEEK, were you on layoff from a job?
Yes ➜ SKIP to question 40c
G
No
Answer questions 46a – f if you worked in the past 5 years
(since 2015). Otherwise, SKIP to question 47.
b. LAST WEEK, were you TEMPORARILY absent from a
job or business?
46.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 43a
DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment
you had last week.
No ➜ SKIP to question 41
If you had more than one job, describe the one at which the most
hours were worked. If you did not work last week, describe the
most recent employment in the past five years (since 2015).
c. Have you been informed that you will be recalled to
work within the next 6 months OR been given a date to
return to work?
a. Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 42
No
During the LAST 4 WEEKS, have you been ACTIVELY
looking for work?
T
PRIVATE SECTOR EMPLOYEE
41.
For-profit company or organization
Non-profit organization (including tax-exempt and charitable
organizations)
R
AF
Yes
No ➜ SKIP to question 43a
42.
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
LAST WEEK, could you have started a job if offered one,
or returned to work if recalled?
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
Yes, could have gone to work
SELF-EMPLOYED OR OTHER
No, because of own temporary illness
Owner of non-incorporated business, professional practice,
or farm
No, because of all other reasons (in school, etc.)
43.
Owner of incorporated business, professional practice,
or farm
a. When did you last work, even for a few days?
2020
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
D
2019 ➜ SKIP to question 44a
2015 to 2018 ➜ SKIP to G
b. What was the name of your employer, business,
agency, or branch of the Armed Forces?
2014 or earlier, or never worked ➜ SKIP to question 47
Yes
11810074
No ➜ SKIP to G
44.
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)
a. During 2019 (all 52 weeks), did you work EVERY week?
Count paid vacation, paid sick leave, and military service
as work.
Yes ➜ SKIP to question 45
No
d. Was this mainly – Mark I
J
K ONE box.
b. During 2019 (all 52 weeks), how many WEEKS did you
work? Include paid time off and include weeks when you
only worked for a few hours.
manufacturing?
wholesale trade?
Weeks
retail trade?
other (agriculture, construction, service, government, etc.)?
7
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b. LAST YEAR, 2019, did you work at a job or business at
any time?
e. What was your main occupation?
(For example: 4th grade teacher, entry-level plumber)
d. Did you receive any Social Security or Railroad
Retirement income in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe your 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)
e. Did you receive any Supplemental Security Income
(SSI) in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Did you receive any public assistance or welfare
payments from the state or local welfare office in 2019?
INCOME IN 2019
TOTAL AMOUNT – Dollars
Mark K
J the "Yes" box for each type of income you received, and
I
give your best estimate of the TOTAL AMOUNT during 2019.
$
.00
R
AF
No
Mark K
J the "No" box to show types of income NOT received.
I
If your net income was a loss, mark the "Loss" box to the right of
the dollar amount.
g. Did you 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.
For income received jointly, report only your share of the amount
received or earned.
a. Did you receive any wages, salary, commissions,
bonuses, or tips in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
$
$
No
D
TOTAL AMOUNT – Dollars
No
.00
h. Did you have any other sources of income received
regularly such as Department of Veterans Affairs (VA)
payments, unemployment compensation, child support,
or alimony in 2019? Do NOT include lump sum payments
such as money from an inheritance or sale of a home.
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b. Did you have any self-employment income from own
nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
Yes ➜ What was the amount?
Yes ➜ What was the net income after business expenses?
TOTAL AMOUNT – Dollars
TOTAL AMOUNT – Dollars
$
$
.00
Loss
No
48.
What was your total income for 2019? Add entries in questions
47a to 47h; subtract any losses. If net income was a loss, enter
the amount and mark K
J the “Loss” box next to the dollar amount.
I
TOTAL AMOUNT for 2019
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
No
.00
No
c. Did you 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.
$
.00
11810082
47.
T
Yes ➜ What was the amount?
OR
None
.00
Loss
8
$
.00
Loss
| File Type | application/pdf |
| File Modified | 2018-11-26 |
| File Created | 2018-11-21 |