Download:
pdf |
pdfDraft 12 (4-9-2019)
D-JA-AS
(4-9-2019)
OMB No. 0607-1006: Approval Expires 11/30/2021
DC
FLASHCARD
American Samoa
Everyone counts.
The goal of the 2020 Census of American Samoa is to count everyone by collecting information about all adults,
children, and babies living in American Samoa.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of American
Samoa, you are doing your part to help your community plan for hospitals and schools, support local programs,
improve emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of American Samoa is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of American Samoa.
Please turn to the next page to begin using this flashcard.
D-JA-AS - Base prints Black Ink
WHO TO COUNT
We need to count people where
they live and sleep most of the time.
RELATIONSHIP
How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Do NOT include:
Do include:
Same-sex husband/wife/spouse
Same-sex unmarried partner
● College students who live
away from this address most
of the year.
● Babies and children
living here, including
foster children.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
● Armed Forces personnel
● Roommates.
who live away.
● People in a nursing home,
mental hospital, etc. on
April 1, 2020.
● People in jail, prison,
● Boarders.
Brother or sister
Father or mother
Grandchild
● People staying here
on April 1, 2020 who
have no permanent
place to live.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
detention facility, etc.
on April 1, 2020.
Roommate or housemate
Foster child
Other nonrelative
Page 2
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%
HISPANIC ORIGIN
Is this person of Hispanic, Latino, or Spanish origin?
RACE
What is this person’s race? You may choose one or more races.
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 3
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%
BUILDING TYPE
INTERNET
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?
A mobile home
Yes
A one-family house detached from any other house
No
A one-family house attached to one or more houses
Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?
Two houses (American Samoa only)
Three or more houses (American Samoa only)
Yes
A building with 2 apartments
No
A building with 3 or 4 apartments
Do you or any member of this household have access to the
Internet using a –
Yes
A building with 5 to 9 apartments
A building with 10 to 19 apartments
No
a. Cellular data plan for a smartphone or other
mobile device?
A building with 20 to 49 apartments
A building with 50 or more apartments
b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
Boat, RV, van, etc.
c. Satellite Internet service installed in this household?
COMPUTER USE
d. Dial-up Internet service installed in this household?
e. Some other service? – Specify service C
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. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C
Page 4
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%
SOURCE OF WATER
In 2019, did this house, apartment, or mobile home get water
from – Mark I
K all that apply.
J
SEWAGE DISPOSAL
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark I
K ONE box.
J
A public system?
Public sewer
A cistern, catchment, tanks, or drums?
Septic tank or cesspool
A delivery vendor or water truck?
Other
A supermarket or grocery store?
Some other source (a standpipe, spring, individual well, etc.)?
Page 5
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in American Samoa
What is the highest degree or level of school this person has
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
grade or highest degree received.
Yes, born in another U.S. state or U.S. territory
NO SCHOOLING COMPLETED
Is this person a citizen or national of the United States?
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
No schooling completed
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)
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 6
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%
HEALTH INSURANCE
PERIOD OF SERVICE
When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
a. Insurance through a current or former employer
or union (of this person or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by this person or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 7
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%
TRANSPORTATION TO WORK
How did this person 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
TYPE OF WORKER
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 I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 8
FORM D-JA-AS (4-9-2019)
D-JA-AS - Base prints Black Ink
D-JA-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 9 (4-12-2019)
D-JA-GE-AS
(4-12-2019)
DC
OMB No. 0607-1006: Approval Expires 11/30/2021
INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
American Samoa
Everyone counts.
The goal of the 2020 Census of American Samoa is to count everyone by collecting information about all adults,
children, and babies living in American Samoa.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of American
Samoa, you are doing your part to help your community plan for hospitals and schools, support local programs,
improve emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of American Samoa is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of American Samoa.
Please turn to the next page to begin using this flashcard.
D-JA-GE-AS - Base prints Black Ink
HISPANIC ORIGIN
Are you of Hispanic, Latino, or Spanish origin?
RACE
What is your race?
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 1
FORM D-JA-GE-AS (4-12-2019)
D-JA-GE-AS - Base prints Black Ink
D-JA-GE-AS - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in American Samoa
What is the highest degree or level of school you have
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
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
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
No schooling completed
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)
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
FORM D-JA-GE-AS (4-12-2019)
D-JA-GE-AS - Base prints Black Ink
D-JA-GE-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%
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 you 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 you or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by you or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 3
FORM D-JA-GE-AS (4-12-2019)
D-JA-GE-AS - Base prints Black Ink
D-JA-GE-AS - Tone prints Pantone #6 Cyan 10% and 20%
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
TYPE OF WORKER
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
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 4
FORM D-JA-GE-AS (4-12-2019)
D-JA-GE-AS - Base prints Black Ink
D-JA-GE-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 6 (4-12-2019)
D-JA-GE-GU
(4-12-2019)
DC
OMB No. 0607-1006: Approval Expires 11/30/2021
INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
Guam
Everyone counts.
The goal of the 2020 Census of Guam is to count everyone by collecting information about all adults, children,
and babies living in Guam.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of Guam, you
are doing your part to help your community plan for hospitals and schools, support local programs, improve
emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of Guam is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of Guam.
Please turn to the next page to begin using this flashcard.
D-JA-GE-GU - Base prints Black Ink
HISPANIC ORIGIN
Are you of Hispanic, Latino, or Spanish origin?
RACE
What is your race?
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 1
FORM D-JA-GE-GU (4-12-2019)
D-JA-GE-GU - Base prints Black Ink
D-JA-GE-GU - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in Guam
What is the highest degree or level of school you have
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
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
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
No schooling completed
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)
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
FORM D-JA-GE-GU (4-12-2019)
D-JA-GE-GU - Base prints Black Ink
D-JA-GE-GU - Tone prints Pantone #6 Cyan 10%, 20% and 100%
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 you 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 you or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by you or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 3
FORM D-JA-GE-GU (4-12-2019)
D-JA-GE-GU - Base prints Black Ink
D-JA-GE-GU - Tone prints Pantone #6 Cyan 10% and 20%
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
TYPE OF WORKER
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
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 4
FORM D-JA-GE-GU (4-12-2019)
D-JA-GE-GU - Base prints Black Ink
D-JA-GE-GU - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 6 (4-12-2019)
D-JA-GE-MI
(4-12-2019)
DC
OMB No. 0607-1006: Approval Expires 11/30/2021
Commonwealth of the
Northern Mariana Islands
INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
Everyone counts.
The goal of the 2020 Census of the Commonwealth of the Northern Mariana Islands is to count everyone by
collecting information about all adults, children, and babies living in the Commonwealth of the Northern Mariana
Islands.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the
Commonwealth of the Northern Mariana Islands, you are doing your part to help your community plan for
hospitals and schools, support local programs, improve emergency services, construct roads, inform businesses
looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of the Commonwealth of the Northern Mariana Islands is required. It is a way to
say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of the
Commonwealth of the Northern Mariana Islands.
Please turn to the next page to begin using this flashcard.
D-JA-GE-MI - Base prints Black Ink
HISPANIC ORIGIN
Are you of Hispanic, Latino, or Spanish origin?
RACE
What is your race?
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 1
FORM D-JA-GE-MI (4-12-2019)
D-JA-GE-MI - Base prints Black Ink
D-JA-GE-MI - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
Are you a citizen or national of the United States?
Yes, born in the Commonwealth of the Northern Mariana
Islands
HIGHEST DEGREE or LEVEL OF SCHOOL
What is the highest degree or level of school you have
COMPLETED? Mark I
K ONE box. If currently enrolled, mark
J
the previous grade or highest degree received.
NO SCHOOLING COMPLETED
Yes, born in another U.S. state or U.S. territory
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
No schooling completed
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)
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
FORM D-JA-GE-MI (4-12-2019)
D-JA-GE-MI - Base prints Black Ink
D-JA-GE-MI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
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 you 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 you or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by you or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 3
FORM D-JA-GE-MI (4-12-2019)
D-JA-GE-MI - Base prints Black Ink
D-JA-GE-MI - Tone prints Pantone #6 Cyan 10% and 20%
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
TYPE OF WORKER
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
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 4
FORM D-JA-GE-MI (4-12-2019)
D-JA-GE-MI - Base prints Black Ink
D-JA-GE-MI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 7 (4-12-2019)
D-JA-GE-VI
(4-12-2019)
DC
OMB No. 0607-1006: Approval Expires 11/30/2021
U.S. Virgin Islands
INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
Everyone counts.
The goal of the 2020 Census of the U.S. Virgin Islands is to count everyone by collecting information about all
adults, children, and babies living in the U.S. Virgin Islands.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the U.S.
Virgin Islands, you are doing your part to help your community plan for hospitals and schools, support local
programs, improve emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of the U.S. Virgin Islands is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of the
U.S. Virgin Islands.
Please turn to the next page to begin using this flashcard.
D-JA-GE-VI - Base prints Black Ink
HISPANIC ORIGIN
Are you of Hispanic, Latino, or Spanish origin?
RACE
What is your race?
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 1
FORM D-JA-GE-VI (4-12-2019)
D-JA-GE-VI - Base prints Black Ink
D-JA-GE-VI - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in the U.S. Virgin Islands
What is the highest degree or level of school you have
COMPLETED? Mark I
K ONE box. If currently enrolled, mark
J
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
Yes, U.S. citizen by naturalization – Print year
of naturalization. C
No schooling completed
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)
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
FORM D-JA-GE-VI (4-12-2019)
D-JA-GE-VI - Base prints Black Ink
D-JA-GE-VI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
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 you 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 you or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by you or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 3
FORM D-JA-GE-VI (4-12-2019)
D-JA-GE-VI - Base prints Black Ink
D-JA-GE-VI - Tone prints Pantone #6 Cyan 10% and 20%
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
TYPE OF WORKER
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
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 4
FORM D-JA-GE-VI (4-12-2019)
D-JA-GE-VI - Base prints Black Ink
D-JA-GE-VI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 10 (4-12-2019)
D-JA-GE-VI(S)
(4-12-2019)
DC
Num. de OMB No. 0607-1006: Aprobado hasta 11/30/2021
U.S. Virgin Islands
TARJETA DE REFERENCIA PARA EL
CUESTIONARIO INDIVIDUAL DEL CENSO
Todos cuentan.
El objetivo del Censo del 2020 de las Islas Vírgenes de los EE. UU. es contar a todos mediante la recopilación de
información sobre adultos, niños y bebés que vivan en las Islas Vírgenes de los EE. UU.
Los datos del censo son importantes.
La Constitución de los EE. UU. requiere un censo cada 10 años. Cuando usted responde al Censo del 2020 de
las Islas Vírgenes de los EE. UU., está haciendo su parte para ayudar a su comunidad a planificar para
hospitales y escuelas, apoyar programas locales, mejorar servicios de emergencia, construir caminos, informar a
las empresas que desean agregar puestos de trabajo y más.
Participar es su deber cívico.
Completar el Censo del 2020 de las Islas Vírgenes de los EE. UU. es obligatorio. Es una manera de decir
"Yo cuento".
Su información es confidencial.
La ley federal protege sus respuestas. Sus respuestas se pueden usar solo para producir estadísticas y no
pueden ser usadas en su contra por ninguna agencia del gobierno o tribunal.
Use esta tarjeta de referencia para responder preguntas del Censo del 2020 de las
Islas Vírgenes de los EE. UU.
Por favor, dé vuelta a la siguiente página para comenzar a usar esta tarjeta de referencia.
D-JA-GE-VI(S) - Base prints Black Ink
ORIGEN HISPANO
¿Es usted de origen hispano, latino o español?
RAZA
¿Cuál es su raza?
Marque I
K una o más casillas Y escriba los orígenes.
J
No, no de origen hispano, latino o español
Sí, mexicano, mexicanoamericano, chicano
Blanca – Escriba, por ejemplo, alemán, irlandés, inglés, italiano,
libanés, egipcio, etc. C
Sí, puertorriqueño
Sí, cubano
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
Vietnamita
Nativa de Hawái
Filipina
Coreana
Samoana
India asiática
Japonesa
Chamorro
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
Página 1
FORM D-JA-GE-VI(S) (4-12-2019)
D-JA-GE-VI(S) - Base prints Black Ink
D-JA-GE-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
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.
Sí, nacido(a) en otro estado o territorio de los EE. UU.
Sí, nacido(a) en el extranjero de padre o madre que es
ciudadano(a) o nacional de los EE. UU.
Sí, ciudadano(a) de los EE. UU. por naturalización – Escriba el
año de naturalización. C
GRADO o NIVEL DE EDUCACIÓN MÁS ALTO
¿Cuál es el grado o nivel de educación más alto que ha
COMPLETADO? Marque I
K UNA casilla. Si está matriculado(a)
J
actualmente, 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
Guardería, preescolar o prekindergarten
Kindergarten
No, no ciudadano(a) o nacional de los EE. UU.
(residente permanente)
Grado 1 al 11 – Especifique el grado, del 1 al 11 C
No, no ciudadano(a) o nacional de los EE. UU.
(residente temporal)
Grado 12 – 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)
Página 2
FORM D-JA-GE-VI(S) (4-12-2019)
D-JA-GE-VI(S) - Base prints Black Ink
D-JA-GE-VI(S) - Tone prints Pantone #6 Cyan 10%, 20% and 100%
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.
Yes
No
a. Seguro a través de su empleador o sindicato
(union), actual o previo (suyo o de cualquier
otro miembro de la familia)
b. Seguro adquirido directamente de una compañía
de seguro (por usted o por cualquier
otro miembro de la familia)
¿Cuándo estuvo usted en servicio activo en las Fuerzas Armadas de
los EE. UU.? Marque I
K una casilla para CADA período durante el cual
J
usted prestó servicio activo, aunque fuera solo por parte del período.
Septiembre del 2001 o después
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)
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 discapacidades
Enero del 1947 a junio del 1950
Segunda Guerra Mundial (diciembre del 1941 a diciembre
del 1946)
Noviembre del 1941 o antes
e. TRICARE u otro seguro de salud militar
f.
Administración de Veteranos (VA) (inscrito[a] en
el sistema de cuidado de salud militar de la VA)
g. Servicio de Salud Indio (Indian Health Service)
h. Cualquier otro tipo de seguro de salud o plan
de cobertura de salud – Especifique C
Página 3
FORM D-JA-GE-VI(S) (4-12-2019)
D-JA-GE-VI(S) - Base prints Black Ink
D-JA-GE-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
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
J
más distancia.
Automóvil, camión o van/autobús privado
TIPO DE TRABAJADOR
¿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
EMPLEADO(A) DEL SECTOR PRIVADO
Van/autobús público
Empresa u organización con fines de lucro
Taxi
Organización sin fines de lucro (incluso organizaciones
exentas de impuestos y organizaciones benéficas)
Motocicleta
EMPLEADO(A) DEL GOBIERNO
Bicicleta
Gobierno local o territorial
(por ejemplo: escuela primaria pública)
Caminó
Avión o hidroavión
Lancha, ferri o taxi acuático
Trabajó en el hogar
Servicio activo en las Fuerzas Armadas de EE. UU.
o en los Cuerpos Comisionados
Empleado(a) civil del gobierno federal
EMPLEADO(A) POR CUENTA PROPIA U OTRO TIPO DE EMPLEO
Otro método
Propietario(a) de un negocio, práctica profesional o finca
no incorporados
Propietario(a) de un negocio, práctica profesional o finca
incorporados
Trabajo sin paga en un negocio o finca de la familia con
fines de lucro 15 horas o más por semana
Página 4
FORM D-JA-GE-VI(S) (4-12-2019)
D-JA-GE-VI(S) - Base prints Black Ink
D-JA-GE-VI(S) - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 8 (4-9-2019)
D-JA-GU
(4-9-2019)
OMB No. 0607-1006: Approval Expires 11/30/2021
DC
FLASHCARD
Guam
Everyone counts.
The goal of the 2020 Census of Guam is to count everyone by collecting information about all adults, children,
and babies living in Guam.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of Guam, you
are doing your part to help your community plan for hospitals and schools, support local programs, improve
emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of Guam is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of Guam.
Please turn to the next page to begin using this flashcard.
D-JA-GU - Base prints Black Ink
WHO TO COUNT
We need to count people where
they live and sleep most of the time.
RELATIONSHIP
How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Do NOT include:
Do include:
Same-sex husband/wife/spouse
Same-sex unmarried partner
● College students who live
away from this address most
of the year.
● Babies and children
living here, including
foster children.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
● Armed Forces personnel
● Roommates.
who live away.
● People in a nursing home,
mental hospital, etc. on
April 1, 2020.
● People in jail, prison,
● Boarders.
Brother or sister
Father or mother
Grandchild
● People staying here
on April 1, 2020 who
have no permanent
place to live.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
detention facility, etc.
on April 1, 2020.
Roommate or housemate
Foster child
Other nonrelative
Page 2
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%
HISPANIC ORIGIN
Is this person of Hispanic, Latino, or Spanish origin?
RACE
What is this person’s race? You may choose one or more races.
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 3
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%
BUILDING TYPE
INTERNET
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?
A mobile home
Yes
A one-family house detached from any other house
No
A one-family house attached to one or more houses
Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?
Two houses (American Samoa only)
Three or more houses (American Samoa only)
Yes
A building with 2 apartments
No
A building with 3 or 4 apartments
Do you or any member of this household have access to the
Internet using a –
Yes
A building with 5 to 9 apartments
A building with 10 to 19 apartments
No
a. Cellular data plan for a smartphone or other
mobile device?
A building with 20 to 49 apartments
A building with 50 or more apartments
b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
Boat, RV, van, etc.
c. Satellite Internet service installed in this household?
COMPUTER USE
d. Dial-up Internet service installed in this household?
e. Some other service? – Specify service C
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. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C
Page 4
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%
SOURCE OF WATER
In 2019, did this house, apartment, or mobile home get water
from – Mark I
K all that apply.
J
SEWAGE DISPOSAL
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark I
K ONE box.
J
A public system?
Public sewer
A cistern, catchment, tanks, or drums?
Septic tank or cesspool
A delivery vendor or water truck?
Other
A supermarket or grocery store?
Some other source (a standpipe, spring, individual well, etc.)?
Page 5
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in Guam
What is the highest degree or level of school this person has
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
grade or highest degree received.
Yes, born in another U.S. state or U.S. territory
NO SCHOOLING COMPLETED
Is this person a citizen or national of the United States?
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
No schooling completed
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)
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 6
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10%, 20% and 100%
HEALTH INSURANCE
PERIOD OF SERVICE
When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
a. Insurance through a current or former employer
or union (of this person or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by this person or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 7
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%
TRANSPORTATION TO WORK
How did this person 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
TYPE OF WORKER
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 I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 8
FORM D-JA-GU (4-9-2019)
D-JA-GU - Base prints Black Ink
D-JA-GU - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 9 (4-9-2019)
D-JA-MI
(4-9-2019)
DC
OMB No. 0607-1006: Approval Expires 11/30/2021
FLASHCARD
Commonwealth of the
Northern Mariana Islands
Everyone counts.
The goal of the 2020 Census of the Commonwealth of the Northern Mariana Islands is to count everyone by
collecting information about all adults, children, and babies living in the Commonwealth of the Northern Mariana
Islands.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the
Commonwealth of the Northern Mariana Islands, you are doing your part to help your community plan for
hospitals and schools, support local programs, improve emergency services, construct roads, inform businesses
looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of the Commonwealth of the Northern Mariana Islands is required. It is a way to
say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of the
Commonwealth of the Northern Mariana Islands.
Please turn to the next page to begin using this flashcard.
D-JA-MI - Base prints Black Ink
WHO TO COUNT
We need to count people where
they live and sleep most of the time.
RELATIONSHIP
How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Do NOT include:
Do include:
Same-sex husband/wife/spouse
Same-sex unmarried partner
● College students who live
away from this address most
of the year.
● Babies and children
living here, including
foster children.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
● Armed Forces personnel
● Roommates.
who live away.
● People in a nursing home,
mental hospital, etc. on
April 1, 2020.
● People in jail, prison,
● Boarders.
Brother or sister
Father or mother
Grandchild
● People staying here
on April 1, 2020 who
have no permanent
place to live.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
detention facility, etc.
on April 1, 2020.
Roommate or housemate
Foster child
Other nonrelative
Page 2
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%
HISPANIC ORIGIN
Is this person of Hispanic, Latino, or Spanish origin?
RACE
What is this person’s race? You may choose one or more races.
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 3
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%
BUILDING TYPE
INTERNET
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?
A mobile home
Yes
A one-family house detached from any other house
No
A one-family house attached to one or more houses
Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?
Two houses (American Samoa only)
Three or more houses (American Samoa only)
Yes
A building with 2 apartments
No
A building with 3 or 4 apartments
Do you or any member of this household have access to the
Internet using a –
Yes
A building with 5 to 9 apartments
A building with 10 to 19 apartments
No
a. Cellular data plan for a smartphone or other
mobile device?
A building with 20 to 49 apartments
A building with 50 or more apartments
b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
Boat, RV, van, etc.
c. Satellite Internet service installed in this household?
COMPUTER USE
d. Dial-up Internet service installed in this household?
e. Some other service? – Specify service C
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. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C
Page 4
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%
SOURCE OF WATER
In 2019, did this house, apartment, or mobile home get water
from – Mark I
K all that apply.
J
SEWAGE DISPOSAL
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark I
K ONE box.
J
A public system?
Public sewer
A cistern, catchment, tanks, or drums?
Septic tank or cesspool
A delivery vendor or water truck?
Other
A supermarket or grocery store?
Some other source (a standpipe, spring, individual well, etc.)?
Page 5
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in the Commonwealth of the Northern Mariana Islands
What is the highest degree or level of school this person has
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
grade or highest degree received.
Yes, born in another U.S. state or U.S. territory
NO SCHOOLING COMPLETED
Is this person a citizen or national of the United States?
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
No schooling completed
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)
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 6
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
HEALTH INSURANCE
PERIOD OF SERVICE
When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
a. Insurance through a current or former employer
or union (of this person or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by this person or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 7
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%
TRANSPORTATION TO WORK
How did this person 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
TYPE OF WORKER
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 I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 8
FORM D-JA-MI (4-9-2019)
D-JA-MI - Base prints Black Ink
D-JA-MI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 8 (4-9-2019)
D-JA-VI
(4-9-2019)
OMB No. 0607-1006: Approval Expires 11/30/2021
DC
FLASHCARD
U.S. Virgin Islands
Everyone counts.
The goal of the 2020 Census of the U.S. Virgin Islands is to count everyone by collecting information about all
adults, children, and babies living in the U.S. Virgin Islands.
Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the U.S.
Virgin Islands, you are doing your part to help your community plan for hospitals and schools, support local
programs, improve emergency services, construct roads, inform businesses looking to add jobs and more.
Taking part is your civic duty.
Completing the 2020 Census of the U.S. Virgin Islands is required. It is a way to say I count.
Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.
Use this flashcard to answer questions from the 2020 Census of the
U.S. Virgin Islands.
Please turn to the next page to begin using this flashcard.
D-JA-VI - Base prints Black Ink
WHO TO COUNT
We need to count people where
they live and sleep most of the time.
RELATIONSHIP
How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Do NOT include:
Do include:
Same-sex husband/wife/spouse
Same-sex unmarried partner
● College students who live
away from this address most
of the year.
● Babies and children
living here, including
foster children.
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
● Armed Forces personnel
● Roommates.
who live away.
● People in a nursing home,
mental hospital, etc. on
April 1, 2020.
● People in jail, prison,
● Boarders.
Brother or sister
Father or mother
Grandchild
● People staying here
on April 1, 2020 who
have no permanent
place to live.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
detention facility, etc.
on April 1, 2020.
Roommate or housemate
Foster child
Other nonrelative
Page 2
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-vi - Tone prints Pantone #6 Cyan 10% and 20%
HISPANIC ORIGIN
Is this person of Hispanic, Latino, or Spanish origin?
RACE
What is this person’s race? You may choose one or more races.
Mark I
K one or more boxes AND print origins.
J
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Yes, Puerto Rican
Yes, Cuban
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 –
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
Page 3
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%
BUILDING TYPE
INTERNET
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?
A mobile home
Yes
A one-family house detached from any other house
No
A one-family house attached to one or more houses
Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?
Two houses (American Samoa only)
Three or more houses (American Samoa only)
Yes
A building with 2 apartments
No
A building with 3 or 4 apartments
Do you or any member of this household have access to the
Internet using a –
Yes
A building with 5 to 9 apartments
A building with 10 to 19 apartments
No
a. Cellular data plan for a smartphone or other
mobile device?
A building with 20 to 49 apartments
A building with 50 or more apartments
b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
Boat, RV, van, etc.
c. Satellite Internet service installed in this household?
COMPUTER USE
d. Dial-up Internet service installed in this household?
e. Some other service? – Specify service C
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. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C
Page 4
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%
SOURCE OF WATER
In 2019, did this house, apartment, or mobile home get water
from – Mark I
K all that apply.
J
SEWAGE DISPOSAL
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark I
K ONE box.
J
A public system?
Public sewer
A cistern, catchment, tanks, or drums?
Septic tank or cesspool
A delivery vendor or water truck?
Other
A supermarket or grocery store?
Some other source (a standpipe, spring, individual well, etc.)?
Page 5
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%
CITIZEN or NATIONAL
HIGHEST DEGREE or LEVEL OF SCHOOL
Yes, born in the U.S. Virgin Islands
What is the highest degree or level of school this person has
COMPLETED? Mark I
K ONE box. If currently enrolled, mark the previous
J
grade or highest degree received.
Yes, born in another U.S. state or U.S. territory
NO SCHOOLING COMPLETED
Is this person a citizen or national of the United States?
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
No schooling completed
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)
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 6
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
HEALTH INSURANCE
PERIOD OF SERVICE
When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
Yes
a. Insurance through a current or former employer
or union (of this person or another family member)
No
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990
b. Insurance purchased directly from an insurance
company (by this person or another family member)
Vietnam Era (August 1964 to April 1975)
c. Medicare, for people 65 and older, or people with
certain disabilities
Korean War (July 1950 to January 1955)
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
World War II (December 1941 to December 1946)
February 1955 to July 1964
January 1947 to June 1950
November 1941 or earlier
e. TRICARE or other military health care
f.
VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Page 7
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%
TRANSPORTATION TO WORK
How did this person 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
TYPE OF WORKER
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 I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
Public van/bus
For-profit company or organization
Taxicab
Non-profit organization (including tax-exempt and charitable
organizations)
Motorcycle
GOVERNMENT EMPLOYEE
Bicycle
Walked
Local or territorial government (for example: public
elementary school)
Plane or seaplane
Active duty U.S. Armed Forces or Commissioned Corps
Boat, ferry, or water taxi
Federal government civilian employee
Worked from home
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Other method
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
Page 8
FORM D-JA-VI (4-9-2019)
D-JA-VI - Base prints Black Ink
D-JA-VI - Tone prints Pantone #6 Cyan 10%, 20% and 100%
Draft 10 (4-12-2019)
D-JA-VI(S)
(4-12-2019)
DC
Num. de OMB No. 0607-1006: Aprobado hasta 11/30/2021
TARJETA DE REFERENCIA
U.S. Virgin Islands
Todos cuentan.
El objetivo del Censo del 2020 de las Islas Vírgenes de los EE. UU. es contar a todos mediante la recopilación
de información sobre adultos, niños y bebés que vivan en las Islas Vírgenes de los EE. UU.
Los datos del censo son importantes.
La Constitución de los EE. UU. requiere un censo cada 10 años. Cuando usted responde al Censo del 2020 de
las Islas Vírgenes de los EE. UU., está haciendo su parte para ayudar a su comunidad a planificar para
hospitales y escuelas, apoyar programas locales, mejorar servicios de emergencia, construir caminos, informar a
las empresas que desean agregar puestos de trabajo y más.
Participar es su deber cívico.
Completar el Censo del 2020 de las Islas Vírgenes de los EE. UU. es obligatorio. Es una manera de decir
"Yo cuento".
Su información es confidencial.
La ley federal protege sus respuestas. Sus respuestas se pueden usar solo para producir estadísticas y no
pueden ser usadas en su contra por ninguna agencia del gobierno o tribunal.
Use esta tarjeta de referencia para responder preguntas del Censo del 2020
de las Islas Vírgenes de los EE. UU.
Por favor, dé vuelta a la siguiente página para comenzar a usar esta tarjeta de referencia.
D-JA-VI(S) - Base prints Black Ink
A QUIÉN CONTAR
Necesitamos contar a las personas
donde viven y duermen la mayor
parte del tiempo.
PARENTESCO
¿Cómo está esta persona relacionada con la Persona 1?
Marque I
K UNA casilla.
J
Esposo(a) del sexo opuesto
Pareja no casada del sexo opuesto
NO incluya:
Incluya:
Esposo(a) del mismo sexo
Pareja no casada del mismo sexo
● Estudiantes universitarios que
no viven en esta dirección la
mayor parte del año.
● Personal de las Fuerzas
Armadas que vive fuera
de aquí.
● Personas que estaban en un
hogar de ancianos o nursing
home, un hospital para
enfermos mentales, etc. el
1 de abril de 2020.
● Bebés y niños que viven aquí,
incluyendo a hijos de crianza
(foster).
● Compañeros de casa o cuarto.
● Inquilinos.
● Personas que se quedaban
aquí el 1 de abril de 2020
y que no tienen lugar
permanente donde vivir.
● Personas que estaban en
una cárcel, una prisión, un
centro de detención, etc.
el 1 de abril de 2020.
Hijo(a) biológico(a) o de sangre
Hijo(a) adoptivo(a)
Hijastro(a)
Hermano(a)
Padre o madre
Nieto(a)
Suegro(a)
Yerno o nuera
Otro pariente
Roommate o compañero(a) de casa
Hijo(a) foster
Otra persona que no es pariente
Página 2
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
ORIGEN HISPANO
¿Es esta persona de origen hispano, latino o español?
RAZA
¿Cuál es la raza de esta persona? Usted puede seleccionar una o más
razas. Marque I
J
K una o más casillas Y escriba los orígenes.
No, no es de origen hispano, latino o español
Sí, mexicano, mexicanoamericano, chicano
Blanca – Escriba, por ejemplo, alemán, irlandés, inglés,
italiano,libanés, egipcio, etc. C
Sí, puertorriqueño
Sí, cubano
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
Vietnamita
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
Pacifico – Escriba, por
ejemplo, tongano, fiyiano,
de las Islas Marshall, etc. C
Alguna otra raza – Escriba la raza o el origen. C
Página 3
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
TIPO DE EDIFICIO
¿Cuál describe mejor este edificio? Incluya todos los apartamentos,
pisos, etc., aunque estén desocupados.
INTERNET
En esta casa, apartamento o casa móvil, ¿tiene usted o algún
otromiembro de este hogar acceso a internet?
Una casa móvil
Sí
Una casa para una sola familia, separada de otras casas
No
Una casa para una sola familia, unida a una o más casas
Dos casas (Samoa Estadounidense solamente)
Tres o más casas (Samoa Estadounidense solamente)
Un edificio con 2 apartamentos
¿Paga usted o algún otro miembro de este hogar a una
compañía de teléfonos celulares o a un proveedor de servicio
de internet para tener acceso a internet?
Sí
No
Un edificio con 3 o 4 apartamentos
Un edificio con 5 a 9 apartamentos
¿Tiene usted o algún otro miembro de este hogar acceso
a internet a través de un –
Yes
Un edificio con 10 a 19 apartamentos
Un edificio con 20 a 49 apartamentos
Un edificio con 50 apartamentos o más
Embarcación, vehículo recreativo (RV), van, etc.
No
a. Plan de datos celulares para un teléfono inteligente
(smartphone) u otro dispositivo móvil?
b. Servicio de internet de banda ancha
(alta velocidad) tales como servicio de cable,
fibra óptica o DSL instalado en este hogar?
c. Servicio de internet por satélite instalado en este hogar?
USO DE COMPUTADORA
En esta casa, apartamento o casa móvil, ¿tiene o usa usted o algún
otro miembro de este hogar alguno de los siguientes tipos de
computadoras?
Yes No
d. Servicio de internet de conexión Dial-up
instalado en este hogar?
e. Algún otro servicio? – Especifique el servicio C
a. Computadora de escritorio o computadora portátil
b. Teléfono inteligente (smartphone)
c. Tableta u otra computadora inalámbrica portátil
d. Algún otro tipo de computadora – Especifique C
Página 4
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
FUENTE DE AGUA
En 2019, ¿esta casa, apartamento o casa móvil recibió agua de –
Marque I
K todas las que correspondan.
J
ELIMINACIÓN DE AGUAS CLOACALES
¿Cuál es el medio PRINCIPAL de eliminación de aguas cloacales de
esta casa, apartamento o casa móvil? Marque I
K UNA casilla.
J
Un sistema público?
Alcantarillado o desagüe público
Una cisterna, zona de captación de agua, tanques o tambores?
Tanque séptico o pozo ciego
Un servicio de entrega o un camión cisterna?
Otro
Un supermercado o tienda de comestibles?
Alguna otra fuente (un tubo vertical, manantial,
pozo individual, etc.)?
Página 5
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
CIUDADANO(A) o NACIONAL
¿Es esta persona ciudadana o nacional de los Estados Unidos?
Sí, nacido(a) en las Islas Vírgenes de los EE. UU.
TÍTULO o NIVEL DE EDUCACIÓN MÁS ALTO
¿Cuál es el título o nivel de educación más alto que esta persona ha
COMPLETADO? Marque I
K UNA casilla. Si está matriculada actualmente,
J
marque el grado escolar anterior o el título más alto recibido.
Sí, nacido(a) en otro estado de los EE. UU. o territorio de los
EE. UU.
NO HA COMPLETADO NINGÚN TÍTULO
Sí, nacido(a) en el extranjero de padre o madre que es ciudadano
(a) o nacional de los EE. UU.
GUARDERÍA O PREESCOLAR HASTA GRADO 12
Sí, es ciudadano(a) de los EE. UU. por naturalización – Escriba el
año de naturalización. C
No ha completado ningún grado
Guardería, preescolar o prekindergarten
Kindergarten
Grado 1 al 11 – Especifique el grado, 1 – 11 C
No, no es ciudadano(a) o nacional de los EE. UU. (residente
permanente)
No, no es ciudadano(a) o nacional de los EE. UU. (residente
temporal)
Grado 12 – SIN DIPLOMA
GRADUADO(A) DE ESCUELA SECUNDARIA O PREPARATORIA
(HIGH SCHOOL)
Diploma de escuela secundaria o preparatoria (high school)
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)
Página 6
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10%, 20% and 100%
SEGURO MÉDICO
PERÍODO DE SERVICIO
¿Tiene esta persona cobertura ACTUALMENTE 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 las
respuestas a – h.
Sí
a. Seguro a través de su empleador o sindicato
(union), actual o previo (de esta persona o de
cualquier otro miembro de la familia)
No
¿Cuándo estuvo esta persona en servicio activo en las Fuerzas
Armadas de los E.E. U.U.? Marque I
K una casilla para CADA período
J
durante el cual esta persona estuvo en servicio activo, aunque fuera solo
por parte del período.
Septiembre del 2001 o después
Agosto del 1990 a agosto del 2001 (incluyendo la Guerra del
Golfo Pérsico)
Mayo del 1975 a julio del 1990
b. Seguro adquirido directamente de una compañía de
seguro (por esta persona o por cualquier otro
miembro de la familia)
Época de Vietnam (agosto del 1964 a abril del 1975)
Febrero del 1955 a julio del 1964
c. Medicare, para personas que tienen 65 años o
más, o personas con ciertas discapacidades
Guerra de Corea (julio del 1950 a enero del 1955)
d. Medicaid, Medical Assistance o cualquier tipo
de plan de asistencia gubernamental para
personas con bajos ingresos o con discapacidades
Segunda Guerra Mundial (diciembre del 1941 a diciembre
del 1946)
Enero del 1947 a junio del 1950
Noviembre del 1941 o antes
e. TRICARE u otro seguro de salud militar
f.
Administración de Veteranos (VA) (inscrito[a] enel
sistema de cuidado de salud militar de la VA)
g. Servicio de Salud Indio (Indian Health Service)
h. Cualquier otro tipo de seguro de salud o plan de
cobertura de salud – Especifique C
Página 7
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%
TRANSPORTE AL TRABAJO
¿Cómo llegó esta persona habitualmente al trabajo LA SEMANA
PASADA? Marque I
K UNA casilla para el medio de transporte que
J
utilizó por más distancia.
Automóvil, camión o van/autobús privado
TIPO DE TRABAJADOR
¿Cuál de las siguientes opciones describe mejor el empleo de
estapersona la semana pasada o el empleo más reciente en los
últimos cinco años (desde 2015)? Marque I
K UNA casilla.
J
EMPLEADO(A) DEL SECTOR PRIVADO
Van/autobús público
Empresa u organización con fines de lucro
Taxi
Organización sin fines de lucro (incluyendo organizaciones
exentas de impuestos y organizaciones benéficas)
Motocicleta
EMPLEADO(A) DEL GOBIERNO
Bicicleta
Gobierno local o territorial
(por ejemplo: escuela primaria pública)
Caminó
Avión o hidroavión
Lancha, ferri o taxi acuático
Trabajó en el hogar
Servicio activo en las Fuerzas Armadas de EE. UU.
o en los Cuerpos Comisionados
Empleado(a) civil del gobierno federal
EMPLEADO(A) POR CUENTA PROPIA U OTRO TIPO DE EMPLEO
Otro método
Propietario(a) de un negocio, práctica profesional o finca
no incorporados
Propietario(a) de un negocio, práctica profesional o finca
incorporados
Trabajo sin paga en un negocio o finca de la familia con
fines de lucro 15 horas o más por semana
Página 8
FORM D-JA-VI(S) (4-12-2019)
D-JA-VI(S) - Base prints Black Ink
D-JA-VI(S) - Tone prints Pantone #6 Cyan 10%, 20% and 100%
| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2019-07-03 |
| File Created | 2019-04-24 |