Island Areas Censuses - Group Quarters

2020 Census

Island Areas Censuses Group Quarters Materials

Island Areas Censuses - Group Quarters

OMB: 0607-1006

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-1006 can be found here:

2021-11-10 - No material or nonsubstantive change to a currently approved collection
2020-07-02 - No material or nonsubstantive change to a currently approved collection

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FORM

D-ARCP-GE-AS (11-9-2018)

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

This listing contains conﬁdential information, including Title 13 and Personally Identiﬁable Information (PII), the release of which is protected by the Privacy Act of 1974.

1. IDENTIFICATION

GROUP QUARTERS ADDRESS REGISTER
2020 Census of American Samoa

County
Book

2. ASSIGNMENT INFORMATION
Name – Please Print

Employee ID
Number

Telephone Number

Date
Assigned

Crew Leader

Reassigned Enumerator

Enumerator
Reassigned Enumerator

Completed

Certiﬁcation Statement – I certify that the information is true to the best
of my knowledge and the work completed according to Census Bureau
procedures.
The Crew Leader and all Enumerators must sign this certification statement.

Group Quarters
Listed

Date
Number

3. ENUMERATOR DAILY PROGRESS RECORD (LISTING)

People
Enumerated

Date
Number

4. ENUMERATOR DAILY PROGRESS RECORD (ENUMERATION)

Remarks

5. OFFICE USE ONLY
Name of Reviewer

Date

Initials

The contents of this Address Register are conﬁdential by law
(Title 13, U.S. Code). It may be seen only by sworn persons with
a need to know and used solely for statistical purposes.

CREW LEADER REVIEW CHECKLIST

Before sending to the Census Ofﬁce, verify the following:
The Enumerator has made entries in a legible manner.
All appropriate fields are completed in the Address Listing Page for Group Quarters.
There are no duplicate addresses listed in the Address Listing Page for Group Quarters.
There is an entry of 0 in Pop. Count for vacant units in the Address Listing Page for Group Quarters.

The Enumerator completed the Assignment Information section.

SPECIAL NOTICE

INFORMATION CONTAINED IN THIS ADDRESS REGISTER IS CONFIDENTIAL.
ALL ENTRIES MADE IN THIS ADDRESS REGISTER MUST BE LEGIBLE,
COMPLETE, AND ACCURATE.

FORM D-ARCP-GE-AS (11-9-2018)

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

FORM D-ARLP-GE-AS (11-8-2018)

ADDRESS LISTING PAGE FOR GROUP QUARTERS
2020 Census of American Samoa
County
BCU No.

Facility Name

(4)

(2)
(3)

(4)

(5)

(19) Facility Open between
3/29/2020 and 4/16/2020?
(Y/N)

(1)

(2)

(1)

(2)

(7)

(6)

(21) Contact Attempts
– Enumeration
(Tally)

(22) Mailable?
(Y/N/DK)

(3)

(4)

(7)

(6)

(20) Case Status
– Enumeration

(21) Contact Attempts
– Enumeration
(Tally)

(3)

(4)

(5)

(19) Facility Open between
3/29/2020 and 4/16/2020?
(Y/N)

(7)

(20) Case Status
– Enumeration

(5)

(19) Facility Open between
3/29/2020 and 4/16/2020?
(Y/N)

(6)

(20) Case Status
– Enumeration

Case Status Codes
NV – Left Notice of Visit
A – Appointment
EC – Enumeration Complete RA – Restricted Access
RE – Refusal
GC – Gated Community
LB – Language Barrier
UN – Unsafe
NC – No Contact
OT – Other

(23) Date
Enumerated

(22) Mailable?
(Y/N/DK)

(23) Date
Enumerated

(7)

(6)

(21) Contact Attempts
– Enumeration
(Tally)

(22) Mailable?
(Y/N/DK)

(23) Date
Enumerated

(9)

Village OR

Facility Point of Contact Name

(12)

(14)

(16)

ZIP Code

Estate –
U.S. Virgin Islands Only
(15)

(13)

Title

Telephone
Number
(18)

(17)

(8)

(10)

(12)

(14)

(16)

(9)

(11)

(13)

(15)

(17)

(18)

(26) Pop. Count
(Expected)

(27) Pop. Count
(Final)

(29) JIC1

(30) JIC2

(24) Case Status – FFU

(25) Contact
Attempts –
FFU (Tally)

(28) QC
Action

(8)

(10)

(12)

(14)

(16)

(9)

(11)

(13)

(15)

(17)

(18)

(26) Pop. Count
(Expected)

(27) Pop. Count
(Final)

(29) JIC1

(30) JIC2

(24) Case Status – FFU

(25) Contact
Attempts –
FFU (Tally)

(28) QC
Action

(8)

(10)

(12)

(14)

(16)

(9)

(11)

(13)

(15)

(17)

(18)

(26) Pop. Count
(Expected)

(27) Pop. Count
(Final)

(29) JIC1

(30) JIC2

(24) Case Status – FFU

Abbreviations
Apt – Apartment
BCU – Basic Collection Unit
FFU – Field Followup
MUID – Multi-Unit Identification
No. – Number

Apt/Unit No.

Physical Location
Description
(11)

GQ Type

(2)

Complete Street Name
OR
(10)

(1)

(3)

MUID

(1)

Map Spot
No.
(5)

Address
No.
(8)

Date Assigned

Group Quarters ID

Line
No.

BCU

Pop. – Population
QC – Quality Control
TL – Transitory Location
TU – Transitory Unit
Y/N/DK – Yes, No, or Don’t Know

(25) Contact
Attempts –
FFU (Tally)

(28) QC
Action

Remarks

Page Totals
GQs

HUs

TUs

DC
Your Answers Are Con dential
The U.S. Census Bureau is required by law to protect this information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify anyone. We are conducting the 2020 Census under the authority
of Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use responses to produce statistics. Per the
Federal Cybersecurity Enhancement Act of 2015, data are protected from cybersecurity risks through screening of the systems that
transmit data.
Title 13 of the U.S. Code protects the con dentiality of all this information. Violating the con dentiality of a respondent is a federal crime
with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information provided to the Census Bureau may only be used by a restricted number of
authorized individuals who are sworn for life to protect the con dentiality of individual responses.
For more information about how we protect this information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.

AF
T

You are required by law to respond to the 2020 Census (Title 13, U.S. Code, Sections 141 and 193). The Census Bureau
estimates that completing the questionnaire will take 25 minutes on average. This collection of information has been approved by
the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the bottom left of this notice
confirms this approval. If this number were not displayed, we could not conduct the census.
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.

FORM

D-CN-GE-AS (8-3-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

The U.S. Census Bureau is required by law to protect this information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify anyone. We are conducting the 2020 Census under the authority
of Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use responses to produce statistics. Per the
Federal Cybersecurity Enhancement Act of 2015, data are protected from cybersecurity risks through screening of the systems that
transmit data.
Title 13 of the U.S. Code protects the con dentiality of all this information. Violating the con dentiality of a respondent is a federal crime
with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information provided to the Census Bureau may only be used by a restricted number of
authorized individuals who are sworn for life to protect the con dentiality of individual responses.
For more information about how we protect this information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-GE-AS (8-3-2018)

AF
T

FORM

D-CN-GE-MI (8-3-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-GE-MI (8-3-2018)

AF
T

FORM

D-CN-GE-GU (8-3-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-GE-GU (8-3-2018)

AF
T

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.
Para ver esta información en español, véase al dorso. (For a copy of this information in Spanish, see the reverse side.)

FORM

D-CN-GE-VI(E/S) (6-14-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential
The U.S. Census Bureau is required by law to protect this information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify anyone. We are conducting the 2020 Census under the authority
of Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use responses to produce statistics. Per the
Federal Cybersecurity Enhancement Act of 2015, data are protected from cybersecurity risks through screening of the systems that
transmit data.
Title 13 of the U.S. Code protects the con dentiality of all this information. Violating the con dentiality of a respondent is a federal crime
with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information provided to the Census Bureau may only be used by a restricted number of
authorized individuals who are sworn for life to protect the con dentiality of individual responses.
For more information about how we protect this information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.
You are required by law to respond to the 2020 Census (Title 13, U.S. Code, Sections 141 and 193). The Census Bureau
estimates that completing the questionnaire will take 25 minutes on average. This collection of information has been approved by
the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the bottom left of this notice
confirms this approval. If this number were not displayed, we could not conduct the census.
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.
Para ver esta información en español, véase al dorso. (For a copy of this information in Spanish, see the reverse side.)
OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-GE-VI(E/S) (6-14-2018)

DC
Sus respuestas son con denciales
La O cina del Censo de los EE. UU. está obligada por ley a proteger esta información (Título 13, Código de los EE. UU., Sección 9). A la
O cina del Censo no se le permite divulgar sus respuestas de manera que nadie pudiera ser identi cado. Estamos realizando el Censo del 2020
en conformidad con las Secciones 141, 193, 221 y 223 del Título 13 del Código de los EE. UU. Por ley, la O cina del Censo solo puede usar
respuestas para producir estadísticas. En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética Federal del 2015, los
datos están protegidos contra los riesgos de seguridad cibernética mediante los controles aplicados a los sistemas que los transmiten.
El Título 13 del Código de los EE. UU. protege la con dencialidad de toda la información. Violar la con dencialidad de una persona
encuestada es un delito federal que acarrea sanciones severas, incluso una sentencia de hasta cinco años en una prisión federal, una multa de
hasta $250,000 o ambas. Solo personas autorizadas tienen acceso a los datos almacenados, y la información que se proporcione a la O cina
del Censo puede ser usada solamente por un número limitado de personas autorizadas que han jurado de por vida proteger la con dencialidad
de las respuestas individuales.
Para obtener más información sobre cómo protegemos esta información, visite nuestro sitio web census.gov y haga clic en “Data Protection and
Privacy Policy” en la parte inferior de la página principal. La página sobre protección de datos y normas de privacidad también incluye
información sobre la recopilación, almacenamiento y uso de esos registros; haga clic en "System of Records Notices (SORN)" (Avisos sobre el
Sistema de Registros) y busque Privacy Act System of Records Notice COMMERCE/CENSUS-5, Decennial Census Program (Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad COMMERCE/CENSUS-5, Programa del Censo Decenal).
Gracias por su cooperación. La O cina del Censo agradece su ayuda.

AF
T

A usted se le requiere por ley que responda al Censo del 2020 (Secciones 141 y 193 del Título 13 del Código de los EE. UU.). La
Oficina del Censo calcula que completar el cuestionario tomará 25 minutos como promedio. Esta recopilación de información ha
sido aprobada por la Oficina de Administración y Presupuesto (OMB, por sus siglas en inglés). El número de aprobación de ocho
dígitos de la OMB aparece en la parte inferior izquierda de este aviso confirma la aprobación. De no mostrarse este número, no
podríamos realizar el censo.
Los comentarios sobre el cálculo de tiempo y esfuerzo o cualquier otro aspecto relacionado deben dirigirse a: Paperwork Reduction
Project XXXX-XXXX, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. Puede enviar comentarios
por correo electrónico a <[email protected]>. Use "Paperwork Reduction Project XXXX-XXXX" como tema.
For a copy of this information in English, see the reverse side. (Para ver esta información en inglés, véase al dorso.)

FORM

D-CN-GE-VI(E/S) (6-14-2018)

Núm. de OMB XXXX-XXXX: Aprobado hasta XX/XX/XXXX

Sus respuestas son con denciales
La O cina del Censo de los EE. UU. está obligada por ley a proteger esta información (Título 13, Código de los EE. UU., Sección 9). A la
O cina del Censo no se le permite divulgar sus respuestas de manera que nadie pudiera ser identi cado. Estamos realizando el Censo del 2020
en conformidad con las Secciones 141, 193, 221 y 223 del Título 13 del Código de los EE. UU. Por ley, la O cina del Censo solo puede usar
respuestas para producir estadísticas. En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética Federal del 2015, los
datos están protegidos contra los riesgos de seguridad cibernética mediante los controles aplicados a los sistemas que los transmiten.
El Título 13 del Código de los EE. UU. protege la con dencialidad de toda la información. Violar la con dencialidad de una persona
encuestada es un delito federal que acarrea sanciones severas, incluso una sentencia de hasta cinco años en una prisión federal, una multa de
hasta $250,000 o ambas. Solo personas autorizadas tienen acceso a los datos almacenados, y la información que se proporcione a la O cina
del Censo puede ser usada solamente por un número limitado de personas autorizadas que han jurado de por vida proteger la con dencialidad
de las respuestas individuales.
Para obtener más información sobre cómo protegemos esta información, visite nuestro sitio web census.gov y haga clic en “Data Protection and
Privacy Policy” en la parte inferior de la página principal. La página sobre protección de datos y normas de privacidad también incluye
información sobre la recopilación, almacenamiento y uso de esos registros; haga clic en "System of Records Notices (SORN)" (Avisos sobre el
Sistema de Registros) y busque Privacy Act System of Records Notice COMMERCE/CENSUS-5, Decennial Census Program (Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad COMMERCE/CENSUS-5, Programa del Censo Decenal).
Gracias por su cooperación. La O cina del Censo agradece su ayuda.
A usted se le requiere por ley que responda al Censo del 2020 (Secciones 141 y 193 del Título 13 del Código de los EE. UU.). La
Oficina del Censo calcula que completar el cuestionario tomará 25 minutos como promedio. Esta recopilación de información ha
sido aprobada por la Oficina de Administración y Presupuesto (OMB, por sus siglas en inglés). El número de aprobación de ocho
dígitos de la OMB aparece en la parte inferior izquierda de este aviso confirma la aprobación. De no mostrarse este número, no
podríamos realizar el censo.
Los comentarios sobre el cálculo de tiempo y esfuerzo o cualquier otro aspecto relacionado deben dirigirse a: Paperwork Reduction
Project XXXX-XXXX, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. Puede enviar comentarios
por correo electrónico a <[email protected]>. Use "Paperwork Reduction Project XXXX-XXXX" como tema.
For a copy of this information in English, see the reverse side. (Para ver esta información en inglés, véase al dorso.)
Núm. de OMB XXXX-XXXX: Aprobado hasta XX/XX/XXXX

FORM

D-CN-GE-VI(E/S) (6-14-2018)

Draft 3 (7-5-2018)

D-JA-GE-AS

(7-5-2018)

GROUP QUARTERS ENUMERATOR
FLASHCARD

AF
T

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

D-JA-GE-AS - Base prints Black Ink

HISPANIC ORIGIN

RACE

Are you of Hispanic, Latino, or Spanish origin?

What is your race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

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

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

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

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

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

Some other race – Print race or origin. C

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CITIZEN or NATIONAL

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school you have
J
K ONE box. If currently enrolled, mark
COMPLETED? Mark I

Are you a citizen or national of the United States?
Yes, born in American Samoa ➜ SKIP to question 11a

the previous grade or highest degree received.

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

NO SCHOOLING COMPLETED

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

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

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

No schooling completed

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)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

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

Page 2

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HEALTH INSURANCE

PERIOD OF SERVICE

When did you serve on active duty in the U.S. Armed Forces?
Mark I
K a box for EACH period in which this person served, even if just
J
for part of the period.

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

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

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by you or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

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

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TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment
you had last week.
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).

Public van/bus
Taxicab

Bicycle

AF
T

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Walked

For-pro t company or organization

Plane or seaplane

Non-pro t organization (including tax-exempt and charitable
organizations)

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a

GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)

Other method

TYPE OF WORKER

Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-pro t family business or farm
for 15 hours or more per week

Page 4

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D-JA-GE-AS - Tone prints Pantone #6 Cyan 10% and 20%

Draft 1 (7-10-2018)

D-JA-GE-MI

(7-10-2018)

GROUP QUARTERS ENUMERATOR
FLASHCARD

AF
T

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

D-JA-GE-MI - Base prints Black Ink

HISPANIC ORIGIN

RACE

Are you of Hispanic, Latino, or Spanish origin?

What is your race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

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

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

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

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

Some other race – Print race or origin. C

Page 1

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CITIZEN or NATIONAL

What is the highest degree or level of school you have
J
K ONE box. If currently enrolled, mark
COMPLETED? Mark I

Are you a citizen or national of the United States?
Yes, born in the Commonwealth of the Northern Mariana
Islands ➜ SKIP to question 11a
Yes, born in another U.S. state or territory

NO SCHOOLING COMPLETED

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

of naturalization C

the previous grade or highest degree received.

No schooling completed

Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year

HIGHEST DEGREE or LEVEL OF SCHOOL

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)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

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HEALTH INSURANCE

PERIOD OF SERVICE

When did you serve on active duty in the U.S. Armed Forces?
Mark I
K a box for EACH period in which this person served, even if just
J
for part of the period.

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

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

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by you or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

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

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TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle

AF
T

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Walked

For-pro t company or organization

Plane or seaplane

Non-pro t organization (including tax-exempt and charitable
organizations)

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a

GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)

Other method

TYPE OF WORKER

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D-JA-GE-GU

(7-10-2018)

GROUP QUARTERS ENUMERATOR
FLASHCARD

AF
T

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

D-JA-GE-GU - Base prints Black Ink

HISPANIC ORIGIN

RACE

Are you of Hispanic, Latino, or Spanish origin?

What is your race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

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

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

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

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

Some other race – Print race or origin. C

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CITIZEN or NATIONAL

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school you have
J
K ONE box. If currently enrolled, mark
COMPLETED? Mark I

Are you a citizen or national of the United States?
Yes, born in Guam ➜ SKIP to question 11a

the previous grade or highest degree received.

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

NO SCHOOLING COMPLETED

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

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

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

No schooling completed

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)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

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HEALTH INSURANCE

PERIOD OF SERVICE

When did you serve on active duty in the U.S. Armed Forces?
Mark I
K a box for EACH period in which this person served, even if just
J
for part of the period.

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

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

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by you or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

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

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TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle

AF
T

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Walked

For-pro t company or organization

Plane or seaplane

Non-pro t organization (including tax-exempt and charitable
organizations)

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a

GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)

Other method

TYPE OF WORKER

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Draft 1 (7-10-2018)

D-JA-GE-VI

(7-10-2018)

GROUP QUARTERS ENUMERATOR
FLASHCARD

AF
T

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

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HISPANIC ORIGIN

RACE

Are you of Hispanic, Latino, or Spanish origin?

What is your race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

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

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

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

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

Some other race – Print race or origin. C

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CITIZEN or NATIONAL

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school you have
J
K ONE box. If currently enrolled, mark
COMPLETED? Mark I

Are you a citizen or national of the United States?
Yes, born in the U.S. Virgin Islands ➜ SKIP to question 11a

the previous grade or highest degree received.

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

NO SCHOOLING COMPLETED

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

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

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

No schooling completed

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)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

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HEALTH INSURANCE

PERIOD OF SERVICE

When did you serve on active duty in the U.S. Armed Forces?
Mark I
K a box for EACH period in which this person served, even if just
J
for part of the period.

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

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

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by you or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

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

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TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle

AF
T

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Walked

For-pro t company or organization

Plane or seaplane

Non-pro t organization (including tax-exempt and charitable
organizations)

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a

GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)

Other method

TYPE OF WORKER

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D-JA-GE-VI(S)

(8-6-2018)

TARJETA DE REFERENCIA PARA
ENUMERADORES DE
ALOJAMIENTOS DE GRUPO

AF
T

Num. de OMB No. xxxx-xxxx: Aprobado hasta xx/xx/xxxx

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ORIGEN HISPANO

RAZA

¿Es usted de origen hispano, latino o español?

¿Cuál es su raza?
Mark I
K una o más casillas Y escriba los orígenes.
J

No, no de origen hispano, latino o español
Blanca – Escriba, por ejemplo, alemán, irlandés, inglés, italiano,
libanés, egipcio, etc. C

Sí, mexicano, mexicanoamericano, chicano

Sí, cubano

AF
T

Sí, puertorriqueño

Sí, de otro origen hispano, latino o español – Escriba, por ejemplo,
salvadoreño, dominicano, colombiano, guatemalteco, español,
ecuatoriano, etc. C

Negra o afroamericana – Escriba, por ejemplo, afroamericano,
jamaiquino, haitiano, nigeriano, etíope, somalí, etc. C

Indígena de las Américas o nativa de Alaska – Escriba el nombre
de la(s) tribu(s) en la(s) que está inscrita o la(s) tribu(s) principal(es),
por ejemplo, Navajo Nation, Blackfeet Tribe, maya, azteca, Native
Village of Barrow Inupiat Traditional Government, Nome Eskimo
Community, etc. C

China

Japonesa

Nativa de Hawái

Filipina

Coreana

Samoana

India asiática

Japonesa

Chamorra

Otra asiática –
Escriba, por
ejemplo, pakistaní,
camboyano, hmong,
etc. C

Otra de las islas del
Pacífico – Escriba por
ejemplo, tongano,
fiyiano, de las Islas,
Marshall, etc. C

Alguna otra raza – Escriba la raza o el origen. C

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CIUDADANO(A) o NACIONAL

¿Es usted ciudadano(a) o nacional de los Estados Unidos?
Sí, nacido(a) en las Islas Vírgenes de los EE. UU. ➜ PASE a la
pregunta 11a
Sí, nacido(a) en otro estado o territorio de los EE. UU.

¿Cuál es el grado o nivel de educación más alto que ha
COMPLETADO? Marque I
K UNA casilla. Si está matriculado(a) actualmente,
J
marque el grado o nivel más alto que haya recibido previamente.

NO HA COMPLETADO NINGÚN GRADO
No ha completado ningún grado
GUARDERÍA O PREESCOLAR HASTA GRADO 12

AF
T

Sí, nacido(a) en el extranjero de padre o madre que es
ciudadano(a) o nacional de los EE. UU.

GRADO o NIVEL DE EDUCACIÓN MÁS ALTO

Sí, ciudadano(a) de los EE. UU. por naturalización –– Escriba el
año de naturalización. C

Guardería, preescolar o prekindergarten
Kindergarten

Grado 1 al 11 – Especifique el grado, del 1 al 11 C

No, no ciudadano(a) o nacional de los EE. UU.
(residente permanente)
No, no ciudadano(a) o nacional de los EE. UU.
(residente temporal)

12th grade – SIN DIPLOMA

GRADUADO(A) DE ESCUELA SECUNDARIA O PREPARATORIA

Diploma de escuela secundaria o preparatoria
GED o examen equivalente

UNIVERSIDAD O ALGUNOS CRÉDITOS UNIVERSITARIOS
Algunos créditos universitarios, pero menos de 1 año de
créditos universitarios
1 año o más de créditos universitarios, sin título
Título asociado universitario (por ejemplo: AA, AS)
Título de licenciatura universitaria (por ejemplo: BA, BS)
DESPUÉS DEL TÍTULO DE LICENCIATURA UNIVERSITARIA
Título de maestría (por ejemplo: MA, MS, MEng, MEd, MSW, MBA)
Título profesional más allá de un título de licenciatura
universitaria (por ejemplo: MD, DDS, DVM, LLB, JD)
Título de doctorado (por ejemplo: PhD, EdD)

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SEGURO MÉDICO

PERÍODO DE SERVICIO

¿Tiene usted ACTUALMENTE cobertura de alguno de los siguientes
tipos de seguros de salud o planes de cobertura de salud? Marque
“Sí” o “No” para CADA tipo de cobertura en los puntos a h.
Sí

a. Seguro a través de su empleador o sindicato
(union), actual o previo (suyo o de cualquier
otro miembro de la familia)

c. Medicare, para personas que tienen 65 años o
más, o personas con ciertas discapacidades
d. Medicaid, Medical Assistance o cualquier tipo de
plan de asistencia gubernamental para personas
con bajos ingresos o con discapacidad
e. TRICARE u otro seguro de salud militar

Agosto del 1990 a agosto del 2001 (incluyendo la Guerra del
Golfo Pérsico)
Mayo del 1975 a julio del 1990
Época de Vietnam (agosto del 1964 a abril del 1975)
Febrero del 1955 a julio del 1964
Guerra de Corea (julio del 1950 a enero del 1955)
Enero del 1947 a junio del 1950
Segunda Guerra Mundial (diciembre del 1941 a diciembre
del 1946)
Noviembre del 1941 o antes

f. Administración de Veteranos (VA) (se ha inscrito en
el sistema de cuidado de salud militar de la VA)

Septiembre del 2001 o después

AF
T

b. Seguro adquirido directamente de una compañía
de seguro (por usted o por cualquier
otro miembro de la familia)

¿Cuándo prestó usted servicio activo en las Fuerzas Armadas de los
EE. UU.? Marque I
K una casilla para CADA período durante el cual usted
J
prestó servicio, aunque fuera solo por parte del período.

g. Servicio de Salud Indio (Indian Health Service)

h. Cualquier otro tipo de seguro de salud o plan
de cobertura de salud – Especifique C

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TRANSPORTE AL TRABAJO

¿Cómo llegó usted habitualmente al trabajo LA SEMANA PASASA?
Marque I
K UNA casilla para el medio de transporte que utilizó por más
J
distancia.
Automóvil, camión o van/autobús privado

DESCRIPCIÓN DEL EMPLEO
La siguiente serie de preguntas se refiere al tipo de empleo que usted
tenía la semana pasada.
Si usted tenía más de un empleo, describa el empleo en el cual trabajó
más horas. Si usted no tenía empleo la semana pasada, describa su
empleo más reciente en los últimos cinco años (desde 2015).

Van/autobús público
Taxi

Bicicleta

AF
T

a. ¿Cuál de las siguientes opciones describe mejor su empleo la
semana pasada o el empleo más reciente en los últimos cinco
años (desde 2015)? Marque I
K UNA casilla.
J

Motocicleta

EMPLEADO(A) DEL SECTOR PRIVADO

Caminó

Empresa u organización con

Avión o hidroavión
Lancha, ferri o taxi acuático

nes de lucro

Organización sin nes de lucro (incluso organizaciones
exentas de impuestos y organizaciones benéficas)

Trabajó en el hogar ➜ PASE a la pregunta 44a

EMPLEADO(A) DEL GOBIERNO
Gobierno local o territorial
(por ejemplo: escuela primaria pública)

Otro método

TIPO DE TRABAJADOR

Servicio activo en las Fuerzas Armadas o en los Cuerpos
Comisionados de los EE. UU.
Empleado(a) civil del gobierno federal
EMPLEADO(A) POR CUENTA PROPIA U OTRO TIPO DE EMPLEO
Dueño(a) de un negocio, práctica profesional o finca
no incorporados
Dueño(a) de un negocio, práctica profesional o finca
incorporados
Trabajo sin paga en un negocio o finca de la familia con
nes de lucro 15 horas o más por semana

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File Type	application/pdf
Author	OneFormUser
File Modified	2018-12-27
File Created	2018-12-27