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OMB No. 0607-1006: Approval Expires 11/30/2021
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
2020 Census of American Samoa
American Samoa
Census Office
County
FOR NPC
USE ONLY
BCU
Map Spot
Within Map Spot ID
➤
➤
APPLY LABEL HERE
Are there any continuation questionnaires for this address?
Yes ➜ Number of continuation questionnaires =
No
Address Number (For example: 5007)
Apt/Unit (For example: Apt A or Lot 3)
Street or Road Name (For example: N Maple Ave)
Physical Description (if applicable)
Village/Municipality/Estate
ZIP Code
Start here
Use a blue or black pen.
1.
S1.
Did you or anyone in this household live or stay here on
April 1, 2020?
We need to count people where they live and sleep most of
the time. Please read the WHO TO COUNT section on the
Flashcard. Based on these instructions, how many
people were living or staying in this
[house/apartment/mobile home] on April 1, 2020?
Yes
Number of people =
No ➜ Skip to S3.
S2.
Does someone usually live at this
[house/apartment/mobile home], or is this a vacation or
seasonal home where no one usually lives?
Usually lives here – Skip to question 1.
2.
Were there any additional people staying here on April 1, 2020
that you did not include in the count in the previous question?
For example:
J
Mark I
K all that apply. Include any additional people on the
person pages.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children
Vacation or seasonal home or held for occasional use – Skip
to page 7.
S3.
Relatives, such as adult children, cousins, or in-laws
On April 1, 2020, was this unit
Occupied by a different household? – Using a knowledgeable
respondent, complete this questionnaire for the people occupying
the household on April 1, 2020.
Nonrelatives, such as roommates or live-in babysitters
Vacant? – Skip to page 7.
No additional people
People staying here temporarily
Not a housing unit – Skip to “Respondent Information”
on page 44.
FORM
D-Q-AS (07-25-2019)
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Person 1
3.
Now I am going to ask you questions about each person
staying here. If there is someone staying here who pays the
rent or owns this residence, I would like to start by listing
him or her as Person 1. If the owner or the person who pays
the rent is not staying here, I can start by listing any adult
staying here as Person 1.
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6.
Please read the HISPANIC ORIGIN section on the Flashcard.
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
What is Person 1’s name?
Print name below and verify the spelling.
Yes, Mexican, Mexican Am., Chicano
Last Name(s)
Yes, Puerto Rican
Yes, Cuban
First Name
4.
MI
Is Person 1 male or female? Mark K
J ONE box.
I
Male
5.
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
7.
Female
Please read the RACE section on the Flashcard.
What is Person 1’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
What is Person 1’s age on April 1, 2020? What is Person 1’s
date of birth? If you don’t know the exact age, please estimate.
For babies less than 1 year old, do not report the age in months.
Report 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Year of birth
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
years
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
➜ If more people were counted in question 1 on the front
page, continue with Person 2 on the next page.
Otherwise, skip to page 7.
2
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1.
What is the name of
Person 2
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
Last Name(s)
6.
First Name
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
For another reason
7.
No
In a nursing home
3.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other relative
Roommate or housemate
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Foster child
Other nonrelative
Some other race – Print race or origin. C
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the front
page, continue with Person 3 on the next page.
Otherwise, skip to page 7.
years
3
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1.
What is the name of
Person 3
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
Last Name(s)
6.
First Name
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
For another reason
7.
No
In a nursing home
3.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other relative
Roommate or housemate
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Foster child
Other nonrelative
Some other race – Print race or origin. C
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the front
page, continue with Person 4 on the next page.
Otherwise, skip to page 7.
years
4
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1.
What is the name of
Person 4
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
Last Name(s)
6.
First Name
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
For another reason
7.
No
In a nursing home
3.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other relative
Roommate or housemate
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Foster child
Other nonrelative
Some other race – Print race or origin. C
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
Year of birth
➜ If more people were counted in question 1 on the front
page, continue with Person 5 on the next page.
Otherwise, skip to page 7.
years
5
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1.
What is the name of
Person 5
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
?
Print name below and verify the spelling.
Last Name(s)
6.
First Name
Please read the HISPANIC ORIGIN section on the Flashcard.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
MI
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
2.
Does this person usually live or stay somewhere else?
For example –
Mark K
J all that apply.
I
With a parent or other relative
In a jail or prison
For college
At a seasonal or
second residence
For a military assignment
For a job or business
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
For another reason
7.
No
In a nursing home
3.
Please read the RACE section on the Flashcard.
What is this person’s race? You may choose one or more races.
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Please read the RELATIONSHIP section on the Flashcard.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other relative
Roommate or housemate
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Foster child
Other nonrelative
Some other race – Print race or origin. C
4.
Is this person male or female? Mark K
J ONE box.
I
Male
5.
Female
What is this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Age on April 1, 2020
Print numbers in boxes.
Month
Day
➜ If more people were counted in question 1 on the front
page of the D-Q-AS, continue with the next person on
an additional continuation questionnaire (D-CQ-AS)
and update the number of continuation questionnaires
on page 1 of the D-Q-AS.
Year of birth
years
6
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Housing
A
Please answer the following questions about this house,
apartment, or mobile home.
Ask questions 4 – 5 if this is a HOUSE OR A MOBILE
HOME; otherwise, SKIP to question 6a.
4.
How many acres is this house or mobile home on?
Less than 1 acre ➜ SKIP to question 6a
1.
Please read the BUILDING TYPE section on the Flashcard.
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
1 to 9.9 acres
10 or more acres
A mobile home
5.
A one-family house detached from any other house
A one-family house attached to one or more houses
None
Two houses (American Samoa only)
$1 to $999
Three or more houses (American Samoa only)
$1,000 to $2,499
A building with 2 apartments
$2,500 to $4,999
A building with 3 or 4 apartments
$5,000 to $9,999
A building with 5 to 9 apartments
$10,000 or more
A building with 10 to 19 apartments
6.
A building with 20 to 49 apartments
A building with 50 or more apartments
a. How many separate rooms are in this house, apartment,
or mobile home? Rooms must be separated by built-in
archways or walls that extend out at least 6 inches and go
from floor to ceiling.
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies, foyers, halls,
or unfinished basements.
Boat, RV, van, etc.
2.
What were the actual sales of all agricultural products from
this property in 2019?
About when was this building first built?
Number of rooms
2000 or later – Specify year C
b. How many of these rooms are bedrooms? Count as
bedrooms those rooms you would list if this house,
apartment, or mobile home were for sale or rent. If this is
an efficiency/studio apartment, print "0".
1990 to 1999
1980 to 1989
Number of bedrooms
1970 to 1979
1960 to 1969
7.
1950 to 1959
Does this house, apartment, or mobile home have –
Yes
1940 to 1949
No
a. Running water?
1939 or earlier
b. A bathtub or shower?
3.
When did PERSON 1 (listed on page 2) move into this
house, apartment, or mobile home?
Month
c. A flush toilet?
Year
d. A sink with a faucet?
e. A stove or range?
f. A refrigerator?
8.
Can you or any member of this household both make and
receive phone calls when at this house, apartment, or mobile
home? Include calls using cell phones, land lines, or other phone
devices.
Yes
No
7
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Housing (continued)
9.
13.
Please read the COMPUTER USE section on the Flashcard.
At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?
Yes
No
Please read the SOURCE OF WATER section on the Flashcard.
In 2019, did this house, apartment, or mobile home get water
from – Mark K
J all that apply.
I
A public system?
A cistern, catchment, tanks, or drums?
A delivery vendor or water truck?
a. Desktop or laptop
A supermarket or grocery store?
b. Smartphone
Some other source (a standpipe, spring, individual well, etc.)?
c. Tablet or other portable wireless computer
14.
d. Some other type of computer – Specify C
Please read the SEWAGE DISPOSAL section on the Flashcard.
What is the MAIN means of sewage disposal for this house,
apartment, or mobile home? Mark K
J ONE box.
I
Public sewer
Septic tank or cesspool
10. a. At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?
Other
Yes
15.
No ➜ SKIP to question 12
a. What is the average monthly cost of electricity for this
house, apartment, or mobile home?
Average monthly cost – Dollars
b. Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?
11.
$
.00
OR
Yes
Included in rent or condominium fee
No ➜ SKIP to question 12
No charge or electricity not used
Please read the INTERNET section on the Flashcard.
Do you or any member of this household have access to the
Internet using a –
Yes
No
b. What is the average monthly cost of gas for this house,
apartment, or mobile home?
Average monthly cost – Dollars
a. Cellular data plan for a smartphone or other
mobile device?
$
.00
b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
Included in rent or condominium fee
c. Satellite Internet service installed in this household?
Included in electricity payment entered above
OR
No charge or gas not used
d. Dial-up Internet service installed in this household?
c. What is the average monthly cost of water and sewer for
this house, apartment, or mobile home?
e. Some other service? – Specify service C
Average monthly cost – Dollars
$
12. How many automobiles, vans, and trucks of one-ton
.00
OR
capacity or less are kept at home for use by members of
this household?
Included in rent or condominium fee
None
No charge
1
d. What is the average monthly cost of oil, coal, kerosene,
wood, etc., for this house, apartment, or mobile home?
2
Average monthly cost – Dollars
3
$
4
.00
OR
5
Included in rent or condominium fee
6 or more
No charge or these fuels not used
8
11820081
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Housing (continued)
C
16.
In 2019, did you or any member of this household receive
benefits from the Food Stamp Program, SNAP (the
Supplemental Nutrition Assistance Program), or NAP
(Nutrition Assistance Program)? Do NOT include WIC, the
School Lunch Program, or assistance from food banks.
Ask questions 20 – 24 if this person or any member of this
household OWNS or IS BUYING this house, apartment, or
mobile home. Otherwise, SKIP to E on the next page.
20.
Yes
About how much do you think this house and lot, apartment,
or mobile home (and lot, if owned) would sell for if it were for
sale?
Amount – Dollars
No
$
17. Is this house, apartment, or mobile home part of a
21.
condominium?
Yes ➜ What is the monthly condominium fee?
For renters, answer only if you pay the condominium fee
in addition to your rent. Otherwise, mark the "None" box.
What were the annual real estate taxes on THIS property in
2019?
Annual amount – Dollars
$
Monthly amount – Dollars
$
.00
.00
OR
.00
None
OR
22.
None
No
What was the annual payment for fire, hazard, typhoon or
hurricane, and flood insurance on THIS property in 2019?
Annual amount – Dollars
18. Is this house, apartment, or mobile home –
$
Mark K
J ONE box.
I
.00
OR
Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.
None
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
23.
Rented?
a. Do you or any member of this household have a
mortgage, deed of trust, contract to purchase, or similar
debt on THIS property?
Occupied without payment of rent? ➜ SKIP to C
Yes, mortgage, deed of trust, or similar debt
Yes, contract to purchase
B
Ask questions 19a and 19b if this house, apartment, or
mobile home is RENTED. Otherwise, SKIP to question 20.
19.
No ➜ SKIP to question 24a
b. How much is the regular monthly mortgage payment on
THIS property? Include payment only on FIRST mortgage
or contract to purchase.
a. What is the monthly rent for this house, apartment, or
mobile home?
Monthly amount – Dollars
Monthly amount – Dollars
$
$
.00
.00
OR
No regular payment required ➜ SKIP to question 24a
b. Does the monthly rent include any meals?
Yes
c. Does the regular monthly mortgage payment include
payments for real estate taxes on THIS property?
No
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required
d. Does the regular monthly mortgage payment include
payments for fire, hazard, typhoon or hurricane, or flood
insurance on THIS property?
Yes, insurance included in mortgage payment
No, insurance paid separately or no insurance
9
11820099
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Housing (continued)
24.
a. Do you or any member of this household have a second
mortgage or a home equity loan on THIS property?
Yes, home equity loan
Yes, second mortgage
Yes, second mortgage and home equity loan
No ➜ SKIP to D
b. How much is the regular monthly payment on all second
or junior mortgages and all home equity loans on THIS
property?
Monthly amount – Dollars
$
.00
OR
No regular payment required
D
Ask question 25 if this is a MOBILE HOME or a BOAT.
Otherwise, SKIP to E.
25.
What were the total annual costs for installment loan
payments, personal property taxes, site rent, marina fee,
registration fees, and license fees on THIS mobile home or
boat and its site/slip fee in 2019? Exclude real estate taxes.
Annual costs – Dollars
$
E
.00
Ask questions about PERSON 1 on the next page if you listed
at least one person on page 2. Otherwise, SKIP to page 44
for further instructions.
10
11820107
§,s"0¤
Person 1
8.
12.
Please copy the name of Person 1 from page 2, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Last Name(s)
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
9.
Where was this person born?
Grade 1 through 11 – Specify grade 1 – 11
C
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
F
GED or alternative credential
Ask question 10 if this person was born outside
American Samoa. Otherwise, SKIP to question 11a.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
10.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Year
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
11.
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
Yes
G
No ➜ SKIP to question 12
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
b. Was that a public school or college, a private school or
college, or home school?
Public school or public college
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
C
College undergraduate years (freshman to senior)
Yes
Graduate or professional school beyond a bachelor’s degree
(for example: MA or PhD program, or medical or law school)
No
11
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Person 1 (continued)
15.
19.
What was this person’s main reason for moving?
Mark K
J ONE box.
I
What is this person’s ancestry or ethnic origin?
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
American Samoa
Yes
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
17.
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
a. Is this person deaf or does he/she have serious difficulty
hearing?
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
No
Very well
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Well
18.
Not well
Yes
Not at all
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12
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Person 1 (continued)
26.
How many times has this person been married?
Once
H
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 2 on page 17.
22.
Three or more times
27.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
In what year did this person last get married?
Year
Yes
No
J
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
No
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or
c. Does this person have difficulty dressing or bathing?
29.
Yes
No
Number of children
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
Yes
I
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 2 on page 17.
23.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No ➜ SKIP to question 30
Yes
c. How long has this grandparent been responsible for
these grandchildren? If the grandparent is financially
responsible for more than one grandchild, answer the
question for the grandchild for whom the grandparent
has been responsible for the longest period of time.
No
24.
What is this person’s marital status?
Now married
Less than 6 months
Widowed
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to J
25.
5 or more years
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
13
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Person 1 (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
35.
On active duty in the past, but not now
31.
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Korean War (July 1950 to January 1955)
Boat, ferry, or water taxi
January 1947 to June 1950
Worked from home ➜ SKIP to question 43a
World War II (December 1941 to December 1946)
Other method
November 1941 or earlier
K
32.
a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
36.
No ➜ SKIP to question 33a
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
b. What is this person’s service-connected disability rating?
0 percent
10 or 20 percent
37.
30 or 40 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
Hour
50 or 60 percent
:
70 percent or higher
33.
a. LAST WEEK, did this person work for pay at a job
(or business)?
Minute
38.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
14
p.m.
How many minutes did it usually take this person to get
from home to work LAST WEEK?
Minutes
Yes ➜ SKIP to question 34
a.m.
11820149
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Person 1 (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
L
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
M
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
45.
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 41
No
40.
DESCRIPTION OF EMPLOYMENT
PRIVATE SECTOR EMPLOYEE
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
For-profit company or organization
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Local or territorial government (for example: public
elementary school)
Yes, could have gone to work
Active duty U.S. Armed Forces or Commissioned Corps
No, because of own temporary illness
Federal government civilian employee
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
42.
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice, or farm
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to M
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
No ➜ SKIP to M
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
15
11820156
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Person 1 (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
46.
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
INCOME IN 2019
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. For income received jointly, report the
appropriate share for each person - or, if that’s not possible,
report the whole amount for only one person. Mark K
J the
I
"No" box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
No
.00
No
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for Person 2 on the next
page. If no one is listed as Person 2 on page 3, SKIP
to page 44 for further instructions.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
16
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Person 2
8.
12.
Please copy the name of Person 2 from page 3, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Last Name(s)
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
9.
Where was this person born?
Grade 1 through 11 – Specify grade 1 – 11
C
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
F
GED or alternative credential
Ask question 10 if this person was born outside
American Samoa. Otherwise, SKIP to question 11a.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
10.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Year
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
11.
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
Yes
G
No ➜ SKIP to question 12
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
b. Was that a public school or college, a private school or
college, or home school?
Public school or public college
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
C
College undergraduate years (freshman to senior)
Yes
Graduate or professional school beyond a bachelor’s degree
(for example: MA or PhD program, or medical or law school)
No
17
11820172
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Person 2 (continued)
15.
19.
What was this person’s main reason for moving?
Mark K
J ONE box.
I
What is this person’s ancestry or ethnic origin?
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
American Samoa
Yes
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
17.
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
a. Is this person deaf or does he/she have serious difficulty
hearing?
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
No
Very well
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Well
18.
Not well
Yes
Not at all
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
18
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Person 2 (continued)
26.
How many times has this person been married?
Once
H
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 3 on page 23.
22.
Three or more times
27.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
In what year did this person last get married?
Year
Yes
No
J
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
No
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or
c. Does this person have difficulty dressing or bathing?
29.
Yes
No
Number of children
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
Yes
I
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 3 on page 23.
23.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No ➜ SKIP to question 30
Yes
c. How long has this grandparent been responsible for
these grandchildren? If the grandparent is financially
responsible for more than one grandchild, answer the
question for the grandchild for whom the grandparent
has been responsible for the longest period of time.
No
24.
What is this person’s marital status?
Now married
Less than 6 months
Widowed
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to J
25.
5 or more years
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
19
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Person 2 (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
35.
On active duty in the past, but not now
31.
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Korean War (July 1950 to January 1955)
Boat, ferry, or water taxi
January 1947 to June 1950
Worked from home ➜ SKIP to question 43a
World War II (December 1941 to December 1946)
Other method
November 1941 or earlier
K
32.
a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
36.
No ➜ SKIP to question 33a
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
b. What is this person’s service-connected disability rating?
0 percent
10 or 20 percent
37.
30 or 40 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
Hour
50 or 60 percent
:
70 percent or higher
33.
a. LAST WEEK, did this person work for pay at a job
(or business)?
Minute
38.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
20
p.m.
How many minutes did it usually take this person to get
from home to work LAST WEEK?
Minutes
Yes ➜ SKIP to question 34
a.m.
11820206
§,s#/¤
Person 2 (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
L
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
M
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
45.
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 41
No
40.
DESCRIPTION OF EMPLOYMENT
PRIVATE SECTOR EMPLOYEE
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
For-profit company or organization
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Local or territorial government (for example: public
elementary school)
Yes, could have gone to work
Active duty U.S. Armed Forces or Commissioned Corps
No, because of own temporary illness
Federal government civilian employee
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
42.
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice, or farm
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to M
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
No ➜ SKIP to M
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
21
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Person 2 (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
46.
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
INCOME IN 2019
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. For income received jointly, report the
appropriate share for each person - or, if that’s not possible,
report the whole amount for only one person. Mark K
J the
I
"No" box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
No
.00
No
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for Person 3 on the next
page. If no one is listed as Person 3 on page 4, SKIP
to page 44 for further instructions.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
22
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Person 3
8.
12.
Please copy the name of Person 3 from page 4, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Last Name(s)
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
9.
Where was this person born?
Grade 1 through 11 – Specify grade 1 – 11
C
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
F
GED or alternative credential
Ask question 10 if this person was born outside
American Samoa. Otherwise, SKIP to question 11a.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
10.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Year
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
11.
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
Yes
G
No ➜ SKIP to question 12
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
b. Was that a public school or college, a private school or
college, or home school?
Public school or public college
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
C
College undergraduate years (freshman to senior)
Yes
Graduate or professional school beyond a bachelor’s degree
(for example: MA or PhD program, or medical or law school)
No
23
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Person 3 (continued)
15.
19.
What was this person’s main reason for moving?
Mark K
J ONE box.
I
What is this person’s ancestry or ethnic origin?
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
American Samoa
Yes
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
17.
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
a. Is this person deaf or does he/she have serious difficulty
hearing?
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
No
Very well
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Well
18.
Not well
Yes
Not at all
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
24
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Person 3 (continued)
26.
How many times has this person been married?
Once
H
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 4 on page 29.
22.
Three or more times
27.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
In what year did this person last get married?
Year
Yes
No
J
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
No
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or
c. Does this person have difficulty dressing or bathing?
29.
Yes
No
Number of children
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
Yes
I
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 4 on page 29.
23.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No ➜ SKIP to question 30
Yes
c. How long has this grandparent been responsible for
these grandchildren? If the grandparent is financially
responsible for more than one grandchild, answer the
question for the grandchild for whom the grandparent
has been responsible for the longest period of time.
No
24.
What is this person’s marital status?
Now married
Less than 6 months
Widowed
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to J
25.
5 or more years
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
25
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Person 3 (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
35.
On active duty in the past, but not now
31.
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Korean War (July 1950 to January 1955)
Boat, ferry, or water taxi
January 1947 to June 1950
Worked from home ➜ SKIP to question 43a
World War II (December 1941 to December 1946)
Other method
November 1941 or earlier
K
32.
a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
36.
No ➜ SKIP to question 33a
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
b. What is this person’s service-connected disability rating?
0 percent
10 or 20 percent
37.
30 or 40 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
Hour
50 or 60 percent
:
70 percent or higher
33.
a. LAST WEEK, did this person work for pay at a job
(or business)?
Minute
38.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
26
p.m.
How many minutes did it usually take this person to get
from home to work LAST WEEK?
Minutes
Yes ➜ SKIP to question 34
a.m.
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Person 3 (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
L
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
M
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
45.
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 41
No
40.
DESCRIPTION OF EMPLOYMENT
PRIVATE SECTOR EMPLOYEE
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
For-profit company or organization
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Local or territorial government (for example: public
elementary school)
Yes, could have gone to work
Active duty U.S. Armed Forces or Commissioned Corps
No, because of own temporary illness
Federal government civilian employee
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
42.
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice, or farm
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to M
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
No ➜ SKIP to M
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
27
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Person 3 (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
46.
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
INCOME IN 2019
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. For income received jointly, report the
appropriate share for each person - or, if that’s not possible,
report the whole amount for only one person. Mark K
J the
I
"No" box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
No
.00
No
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for Person 4 on the next
page. If no one is listed as Person 4 on page 5, SKIP
to page 44 for further instructions.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
28
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Person 4
8.
12.
Please copy the name of Person 4 from page 5, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Last Name(s)
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
9.
Where was this person born?
Grade 1 through 11 – Specify grade 1 – 11
C
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
F
GED or alternative credential
Ask question 10 if this person was born outside
American Samoa. Otherwise, SKIP to question 11a.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
10.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Year
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
11.
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
Yes
G
No ➜ SKIP to question 12
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
b. Was that a public school or college, a private school or
college, or home school?
Public school or public college
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
C
College undergraduate years (freshman to senior)
Yes
Graduate or professional school beyond a bachelor’s degree
(for example: MA or PhD program, or medical or law school)
No
29
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Person 4 (continued)
15.
19.
What was this person’s main reason for moving?
Mark K
J ONE box.
I
What is this person’s ancestry or ethnic origin?
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
American Samoa
Yes
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
17.
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
a. Is this person deaf or does he/she have serious difficulty
hearing?
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
No
Very well
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Well
18.
Not well
Yes
Not at all
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
30
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Person 4 (continued)
26.
How many times has this person been married?
Once
H
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for Person 5 on page 35.
22.
Three or more times
27.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
In what year did this person last get married?
Year
Yes
No
J
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
No
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
None or
c. Does this person have difficulty dressing or bathing?
29.
Yes
No
Number of children
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
Yes
I
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for Person 5 on page 35.
23.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No ➜ SKIP to question 30
Yes
c. How long has this grandparent been responsible for
these grandchildren? If the grandparent is financially
responsible for more than one grandchild, answer the
question for the grandchild for whom the grandparent
has been responsible for the longest period of time.
No
24.
What is this person’s marital status?
Now married
Less than 6 months
Widowed
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to J
25.
5 or more years
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
31
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Person 4 (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
35.
On active duty in the past, but not now
31.
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Korean War (July 1950 to January 1955)
Boat, ferry, or water taxi
January 1947 to June 1950
Worked from home ➜ SKIP to question 43a
World War II (December 1941 to December 1946)
Other method
November 1941 or earlier
K
32.
a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
36.
No ➜ SKIP to question 33a
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
b. What is this person’s service-connected disability rating?
0 percent
10 or 20 percent
37.
30 or 40 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
Hour
50 or 60 percent
:
70 percent or higher
33.
a. LAST WEEK, did this person work for pay at a job
(or business)?
Minute
38.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
32
p.m.
How many minutes did it usually take this person to get
from home to work LAST WEEK?
Minutes
Yes ➜ SKIP to question 34
a.m.
11820321
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Person 4 (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
L
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
M
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
45.
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 41
No
40.
DESCRIPTION OF EMPLOYMENT
PRIVATE SECTOR EMPLOYEE
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
For-profit company or organization
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Local or territorial government (for example: public
elementary school)
Yes, could have gone to work
Active duty U.S. Armed Forces or Commissioned Corps
No, because of own temporary illness
Federal government civilian employee
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
42.
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice, or farm
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to M
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
No ➜ SKIP to M
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
33
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Person 4 (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
46.
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
INCOME IN 2019
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. For income received jointly, report the
appropriate share for each person - or, if that’s not possible,
report the whole amount for only one person. Mark K
J the
I
"No" box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
No
.00
No
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for Person 5 on the next
page. If no one is listed as Person 5 on page 6, SKIP
to page 44 for further instructions.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
34
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Person 5
8.
12.
Please copy the name of Person 5 from page 6, then
continue answering questions below.
Please read the HIGHEST DEGREE or LEVEL OF SCHOOL
section on the Flashcard.
What is the highest degree or level of school this person has
COMPLETED? Mark K
J ONE box. If currently enrolled, mark
I
the previous grade or highest degree received.
Last Name(s)
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school, preschool or pre-kindergarten
Kindergarten
9.
Where was this person born?
Grade 1 through 11 – Specify grade 1 – 11
C
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
F
GED or alternative credential
Ask question 10 if this person was born outside
American Samoa. Otherwise, SKIP to question 11a.
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
10.
When did this person come to live in American Samoa?
If this person came to live in American Samoa more than once,
print latest year.
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Year
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
11.
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
a. At any time since February 1, 2020 has this person
attended school or college? Include only nursery or
preschool, pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to a
high school diploma or a college degree.
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
Yes
G
No ➜ SKIP to question 12
Ask question 13 if this person has a bachelor’s degree or
higher. Otherwise, SKIP to question 14.
b. Was that a public school or college, a private school or
college, or home school?
Public school or public college
13.
This question focuses on this person’s BACHELOR’S
DEGREE. What was the specific major or majors of any
BACHELOR’S DEGREES this person has received?
(For example: chemical engineering, elementary teacher
education, organizational psychology.)
14.
Has this person completed requirements for a vocational
training program at a trade school, hospital, or some other
kind of school for occupational training or place of work?
Do not include academic college courses.
Private school or private college or home school
c. What grade or level was this person attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten
Kindergarten
Grade 1 through 12 – Specify grade 1 – 12
C
College undergraduate years (freshman to senior)
Yes
Graduate or professional school beyond a bachelor’s degree
(for example: MA or PhD program, or medical or law school)
No
35
11820354
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Person 5 (continued)
15.
19.
What was this person’s main reason for moving?
Mark K
J ONE box.
I
What is this person’s ancestry or ethnic origin?
Employment
Family-related
Military
Natural disaster
Housing
Other reason
To attend school
(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)
16.
20.
a. Where was this person’s mother born?
Please read the HEALTH INSURANCE section on the
Flashcard.
Is this person CURRENTLY covered by any of the following
types of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.
American Samoa
Yes
No
a. Insurance through a current or former employer
or union (of this person or another family member)
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people
with certain disabilities
b. Where was this person’s father born?
American Samoa
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
e. TRICARE or other military health care
f. VA (enrolled for VA health care)
17.
a. Does this person speak a language other than English
at home?
g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C
Yes
No ➜ SKIP to question 18
b. What is this language?
21.
a. Is this person deaf or does he/she have serious difficulty
hearing?
For example: Korean, Italian, Spanish, Vietnamese
Yes
c. How well does this person speak English?
No
Very well
b. Is this person blind or does he/she have serious difficulty
seeing even when wearing glasses?
Well
18.
Not well
Yes
Not at all
No
Did this person live in this house or apartment 5 years ago
(on April 1, 2015)?
Person is under 5 years old ➜ SKIP to question 20
Yes, this house ➜ SKIP to question 20
No, different house in American Samoa
No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
36
11820362
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Person 5 (continued)
26.
How many times has this person been married?
Once
H
Two times
Ask questions 22a – c if this person is 5 years old or over.
Otherwise, SKIP to the questions for the next person on page 7
of the D-CQ-AS. If this is the last person, SKIP to page 44.
Three or more times
27.
22.
a. Because of a physical, mental, or emotional condition,
does this person have serious difficulty concentrating,
remembering, or making decisions?
In what year did this person last get married?
Year
Yes
No
J
Ask question 28 if this person is female and 15 years old
or over. Otherwise, SKIP to question 29a.
b. Does this person have serious difficulty walking or
climbing stairs?
28.
Yes
How many babies has this person ever had, not counting
stillbirths? Do not count stepchildren or children she has adopted.
No
None or
Number of children
c. Does this person have difficulty dressing or bathing?
29.
Yes
a. Does this person have any of his/her own grandchildren
under the age of 18 living in this house or apartment?
No
I
Yes
No ➜ SKIP to question 30
Ask question 23 if this person is 15 years old or over.
Otherwise, SKIP to the questions for the next person on page 7
of the D-CQ-AS. If this is the last person, SKIP to page 44.
23.
b. Is this grandparent currently responsible for most of
the basic needs of any grandchildren under the age
of 18 who live in this house or apartment?
Because of a physical, mental, or emotional condition, does
this person have difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No ➜ SKIP to question 30
Yes
c. How long has this grandparent been responsible for
these grandchildren? If the grandparent is financially
responsible for more than one grandchild, answer the
question for the grandchild for whom the grandparent
has been responsible for the longest period of time.
No
24.
25.
What is this person’s marital status?
Now married
Less than 6 months
Widowed
6 to 11 months
Divorced
1 or 2 years
Separated
3 or 4 years
Never married ➜ SKIP to J
5 or more years
In the PAST 12 MONTHS did this person get –
Yes
No
a. Married?
b. Widowed?
c. Divorced?
37
11820370
§,s$y¤
Person 5 (continued)
34.
At what location did this person work LAST WEEK?
American Samoa – Print name of village below. C
30.
Has this person ever served on active duty in the U.S. Armed
Forces, Reserves, or National Guard?
Mark K
J ONE box.
I
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C
Never served in the military ➜ SKIP to question 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a
Now on active duty
35.
On active duty in the past, but not now
31.
Please read the PERIOD OF SERVICE section on the
Flashcard.
When did this person serve on active duty in the U.S. Armed
Forces? Mark K
J a box for EACH period in which this person
I
served, even if just for part of the period.
Please read the TRANSPORTATION TO WORK section on
the Flashcard.
How did this person usually get to work LAST WEEK?
Mark K
J ONE box for the method of transportation used for
I
most of the distance.
Car, truck, or private van/bus
Public van/bus
September 2001 or later
Taxicab
August 1990 to August 2001 (including Persian Gulf War)
Motorcycle
May 1975 to July 1990
Bicycle
Vietnam Era (August 1964 to April 1975)
Walked
February 1955 to July 1964
Plane or seaplane
Korean War (July 1950 to January 1955)
Boat, ferry, or water taxi
January 1947 to June 1950
Worked from home ➜ SKIP to question 43a
World War II (December 1941 to December 1946)
Other method
November 1941 or earlier
K
32.
a. Does this person have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)
Ask question 36 if you marked "Car, truck, or private van/bus"
in question 35. Otherwise, SKIP to question 37.
36.
No ➜ SKIP to question 33a
How many people, including this person, usually rode to
work in the car, truck, or private van/bus LAST WEEK?
Person(s)
b. What is this person’s service-connected disability rating?
0 percent
10 or 20 percent
37.
30 or 40 percent
LAST WEEK, what time did this person’s trip to work
usually begin?
Hour
50 or 60 percent
:
70 percent or higher
33.
a. LAST WEEK, did this person work for pay at a job
(or business)?
Minute
38.
No – Did not work (or retired)
b. LAST WEEK, did this person do ANY work for pay,
even for as little as one hour?
Yes
No ➜ SKIP to question 39a
38
p.m.
How many minutes did it usually take this person to get
from home to work LAST WEEK?
Minutes
Yes ➜ SKIP to question 34
a.m.
11820388
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Person 5 (continued)
44.
During 2019, in the WEEKS WORKED, how many hours did
this person usually work each WEEK?
Usual hours worked each WEEK
L
Ask questions 39 – 42a if this person did NOT work last week.
Otherwise, SKIP to question 42b.
39.
a. LAST WEEK, was this person on layoff from a job?
M
Yes ➜ SKIP to question 39c
Ask questions 45a – f if this person worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.
No
b. LAST WEEK, was this person TEMPORARILY absent
from a job or business?
45.
The next series of questions is about the type of employment
this person had last week.
Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a
If this person had more than one job, describe the one at
which the most hours were worked. If this person did not
work last week, describe the most recent employment in the
past five years (since 2015).
No ➜ SKIP to question 40
c. Has this person been informed that he or she will be
recalled to work within the next 6 months OR been
given a date to return to work?
a. Please read the TYPE OF WORKER section on the
Flashcard.
Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark K
J ONE box.
I
Yes ➜ SKIP to question 41
No
40.
DESCRIPTION OF EMPLOYMENT
PRIVATE SECTOR EMPLOYEE
During the LAST 4 WEEKS, has this person been ACTIVELY
looking for work?
For-profit company or organization
Yes
Non-profit organization (including tax-exempt and charitable
organizations)
No ➜ SKIP to question 42a
41.
GOVERNMENT EMPLOYEE
LAST WEEK, could this person have started a job if offered
one, or returned to work if recalled?
Local or territorial government (for example: public
elementary school)
Yes, could have gone to work
Active duty U.S. Armed Forces or Commissioned Corps
No, because of own temporary illness
Federal government civilian employee
SELF-EMPLOYED OR OTHER
No, because of all other reasons (in school, etc.)
42.
Owner of non-incorporated business, professional practice,
or farm
a. When did this person last work, even for a few days?
2020
Owner of incorporated business, professional practice, or farm
2019 ➜ SKIP to question 43a
Worked without pay in a for-profit family business or farm
for 15 hours or more per week
2015 to 2018 ➜ SKIP to M
2014 or earlier, or never worked ➜ SKIP to question 46
b. What was the name of this person’s employer, business,
agency, or branch of the Armed Forces?
b. LAST YEAR, 2019, did this person work at a job or
business at any time?
Yes
No ➜ SKIP to M
43.
a. During 2019 (all 52 weeks), did this person work EVERY
week? Count paid vacation, paid sick leave, and military
service as work.
c. What kind of business or industry was this?
Include the main activity, product, or service provided at
the location where employed. (For example: elementary
school, residential construction)
Yes ➜ SKIP to question 44
No
b. During 2019 (all 52 weeks), how many WEEKS did this
person work? Include paid time off and include weeks
when the person only worked for a few hours.
Weeks
39
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Person 5 (continued)
d. Did this person receive any Social Security or
Railroad Retirement benefits in 2019?
d. Was this mainly – Mark I
J
K ONE box.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
manufacturing?
wholesale trade?
$
retail trade?
.00
No
other (agriculture, construction, service, government, etc.)?
e. Did this person receive any Supplemental Security
Income (SSI) payments in 2019?
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
f. Describe this person’s most important activities or
duties. (For example: instruct and evaluate students
and create lesson plans, assemble and install pipe
sections and review building plans for work details)
f. Did this person receive any public assistance or public
welfare payments from the state or local welfare office
in 2019?
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
$
.00
No
46.
g. Did this person receive any retirement income, pensions,
survivor or disability income in 2019? Include income from
a previous employer or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k), 403(b) or other
accounts specifically designed for retirement. Do not include
Social Security.
INCOME IN 2019
The next series of questions is about income received during
2019. If the exact amount is not known, please give your best
estimate. If net income was a loss, please give the dollar
amount of the loss. For income received jointly, report the
appropriate share for each person - or, if that’s not possible,
report the whole amount for only one person. Mark K
J the
I
"No" box for the other person.
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
a. Did this person receive any wages, salary, commissions,
bonuses, or tips in 2019?
$
Yes ➜ What was the amount from all jobs before
deductions for taxes, bonds, dues, or other items?
h. Did this person receive income on a regular basis from
any other sources such as Department of Veterans
Affairs (VA) payments, unemployment compensation,
child support or alimony in 2019?
TOTAL AMOUNT – Dollars
$
.00
No
.00
No
Yes ➜ What was the amount?
TOTAL AMOUNT – Dollars
b. Did this person have any self-employment income from
own nonfarm businesses or farm businesses, including
proprietorships and partnerships, in 2019?
$
.00
No
Yes ➜ What was the net income after business expenses?
47.
TOTAL AMOUNT – Dollars
$
What was this person’s total income for 2019?
.00
No
OR
Loss
None
$
.00
TOTAL AMOUNT for 2019
Loss
c. Did this person receive any interest, dividends, net rental
income, royalty income, or income from estates and trusts
in 2019? Report even small amounts credited to an account.
Yes ➜ What was the amount?
➜ Continue with the questions for the next person on
page 7 of the D-CQ-AS. If this is the last person,
SKIP to page 44.
TOTAL AMOUNT – Dollars
$
No
.00
Loss
40
11820404
§,s%-¤
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41
11820412
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42
11820420
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The U.S. Census Bureau estimates that completing the questionnaire will take 40 minutes on average. Send comments regarding this
burden estimate or any other aspect of this burden to: Paperwork Reduction Project 0607-1006, U.S. Census Bureau, DCMD-2H174,
4600 Silver Hill Road, Washington, DC 20233. You may email comments to <[email protected]>. Use “Paperwork
Reduction Project 0607-1006” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval
number 0607-1006 confirms this approval. If this number were not displayed, we could not conduct the census.
43
11820438
§,s%O¤
RESPONDENT INFORMATION
R1. What is your name? Print name below and verify the spelling.
R2. What is your telephone number? We will only contact
you if needed for official Census Bureau business.
Last Name(s)
Telephone Number
–
First Name
–
MI
R3. To confirm: Did you
Live or stay in this [house/apartment/mobile home]
on April 1, 2020?
Address of proxy
Move in to this [house/apartment/mobile home]
after April 1, 2020?
Not live or stay in this [house/apartment/mobile home]
(neighbor or other proxy)?
FOR OFFICIAL USE ONLY
INTERVIEW SUMMARY
A.
B.
Unit Status on April 1, 2020
Occupied
C.
If vacant, ask: Which category best
describes this vacant unit as of
April 1, 2020?
Vacant – regular
01 – 99 = Total people
00 = Vacant
For rent
Vacant – usual home elsewhere
Rented, not occupied
Uninhabitable/demolished/burned out
D.
For sale only
Nonresidential
Sold, not occupied
Empty mobile home/trailer site
Unable to Locate
For seasonal, recreational or
occasional use
Duplicate – record survivor ID below. C
For migrant workers
Interview Outcome Code
UHE
VDC
CO
MOV
REF
REP
PI
OUTCOME CODES:
Other vacant
UHE = Usual Home Elsewhere
MOV= Moved in After April 1
PI = Partial Interview
VDC = Vacant Delete Check
JIC2
JIC1
Number of people
listed on questionnaire(s) =
REF = Refusal
CO = Count Only
REP = Replacement
RECORD OF CONTACT
Type
✗
MM
In-Person
DD
HH
/
MM
Outcome
Type
a.m.
:
In-Person
p.m.
MM
In-Person
DD
HH
/
MM
MM
In-Person
DD
/
HH
MM
:
Telephone
OUTCOME CODES: NV = Left Notice of Visit
MM
a.m.
:
DD
HH
/
MM
p.m.
MM
In-Person
p.m.
Telephone
RE = Refusal
DD
HH
/
CI = Conducted Interview
CERTIFICATION
Outcome
a.m.
:
Telephone
a.m.
Outcome
p.m.
In-Person
Outcome
NC = No Contact
HH
/
MM
p.m.
Telephone
DD
Telephone
Outcome
a.m.
:
MM
MM
Outcome
a.m.
:
p.m.
OT = Other
CL Initials
I certify that the entries I have made on this questionnaire are true
and correct to the best of my knowledge.
Enumerator’s Signature
Month
Employee ID
Day
CLD Number
Month
44
11820446
Day
| File Type | application/pdf |
| File Modified | 2019-07-26 |
| File Created | 2019-07-26 |