Island Areas Censuses - Group Quarters

Draft 10 (08-09-2019)

D-JA-GE-AS

(8-9-2019)

DC

OMB No. 0607-1006: Approval Expires 11/30/2021

INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
American Samoa

Everyone counts.
The goal of the 2020 Census of American Samoa is to count everyone by collecting information about all adults,
children, and babies living in American Samoa.

Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of American
Samoa, you are doing your part to help your community plan for hospitals and schools, support local programs,
improve emergency services, construct roads, inform businesses looking to add jobs and more.

Taking part is your civic duty.
Completing the 2020 Census of American Samoa is required. It is a way to say I count.

Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.

Use this flashcard to answer questions from the 2020 Census of American Samoa.
Please turn to the next page to begin using this flashcard.

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

HISPANIC ORIGIN

Are you of Hispanic, Latino, or Spanish origin?

RACE

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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

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

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

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

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

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

Some other race – Print race or origin. C

FORM D-JA-GE-AS (8-9-2019)

Page 1

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

HEALTH INSURANCE

HIGHEST DEGREE or LEVEL OF SCHOOL

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

Are you CURRENTLY covered by any of the following types
of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.

NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten
Kindergarten

Yes

No

a. Insurance through a current or former employer
or union (of yours or another family member)
b. Insurance purchased directly from an insurance
company (by you or another family member)

Grade 1 through 11 – Specify grade 1 – 11 C

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

12th grade – NO DIPLOMA

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree

e. TRICARE or other military health care
f.

VA (enrolled for VA health care)

g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

FORM D-JA-GE-AS (8-9-2019)

Page 2

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D-JA-GE-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%

PERIOD OF SERVICE

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

TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.

September 2001 or later

Car, truck, or private van/bus

August 1990 to August 2001 (including Persian Gulf War)

Public van/bus

May 1975 to July 1990

Taxicab

Vietnam Era (August 1964 to April 1975)

Motorcycle

February 1955 to July 1964

Bicycle

Korean War (July 1950 to January 1955)

Walked

January 1947 to June 1950

Plane or seaplane

World War II (December 1941 to December 1946)

Boat, ferry, or water taxi

November 1941 or earlier

Worked from home
Other method

FORM D-JA-GE-AS (8-9-2019)

Page 3

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TYPE OF WORKER

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week

Page 4

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D-JA-GE-AS - Tone prints Pantone #6 Cyan 10%, 20% and 100%

Draft 8 (8-9-2019)

D-JA-GE-GU

(8-9-2019)

DC

OMB No. 0607-1006: Approval Expires 11/30/2021

INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD
Guam

Everyone counts.
The goal of the 2020 Census of Guam is to count everyone by collecting information about all adults, children,
and babies living in Guam.

Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of Guam, you
are doing your part to help your community plan for hospitals and schools, support local programs, improve
emergency services, construct roads, inform businesses looking to add jobs and more.

Taking part is your civic duty.
Completing the 2020 Census of Guam is required. It is a way to say I count.

Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.

Use this flashcard to answer questions from the 2020 Census of Guam.
Please turn to the next page to begin using this flashcard.

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

HISPANIC ORIGIN

Are you of Hispanic, Latino, or Spanish origin?

RACE

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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

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

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

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

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

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

Some other race – Print race or origin. C

FORM D-JA-GE-GU (8-9-2019)

Page 1

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

HEALTH INSURANCE

HIGHEST DEGREE or LEVEL OF SCHOOL

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

Are you CURRENTLY covered by any of the following types
of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.

NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten
Kindergarten

Yes

No

a. Insurance through a current or former employer
or union (of yours or another family member)
b. Insurance purchased directly from an insurance
company (by you or another family member)

Grade 1 through 11 – Specify grade 1 – 11 C

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

12th grade – NO DIPLOMA

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree

e. TRICARE or other military health care
f.

VA (enrolled for VA health care)

g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

FORM D-JA-GE-GU (8-9-2019)

Page 2

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

PERIOD OF SERVICE

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

TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.

September 2001 or later

Car, truck, or private van/bus

August 1990 to August 2001 (including Persian Gulf War)

Public van/bus

May 1975 to July 1990

Taxicab

Vietnam Era (August 1964 to April 1975)

Motorcycle

February 1955 to July 1964

Bicycle

Korean War (July 1950 to January 1955)

Walked

January 1947 to June 1950

Plane or seaplane

World War II (December 1941 to December 1946)

Boat, ferry, or water taxi

November 1941 or earlier

Worked from home
Other method

FORM D-JA-GE-GU (8-9-2019)

Page 3

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

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

TYPE OF WORKER

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week

Page 4

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

Draft 8 (08-09-2019)

D-JA-GE-MI

(8-9-2019)

DC

OMB No. 0607-1006: Approval Expires 11/30/2021

Commonwealth of the
Northern Mariana Islands

INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD

Everyone counts.
The goal of the 2020 Census of the Commonwealth of the Northern Mariana Islands is to count everyone by
collecting information about all adults, children, and babies living in the Commonwealth of the Northern Mariana
Islands.

Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the
Commonwealth of the Northern Mariana Islands, you are doing your part to help your community plan for
hospitals and schools, support local programs, improve emergency services, construct roads, inform businesses
looking to add jobs and more.

Taking part is your civic duty.
Completing the 2020 Census of the Commonwealth of the Northern Mariana Islands is required. It is a way to
say I count.

Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.

Use this flashcard to answer questions from the 2020 Census of the
Commonwealth of the Northern Mariana Islands.
Please turn to the next page to begin using this flashcard.

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

HISPANIC ORIGIN

Are you of Hispanic, Latino, or Spanish origin?

RACE

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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

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

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

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

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

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

Some other race – Print race or origin. C

FORM D-JA-GE-MI (8-9-2019)

Page 1

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

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

HEALTH INSURANCE

HIGHEST DEGREE or LEVEL OF SCHOOL

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

Are you CURRENTLY covered by any of the following types
of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.

NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten
Kindergarten

Yes

No

a. Insurance through a current or former employer
or union (of yours or another family member)
b. Insurance purchased directly from an insurance
company (by you or another family member)

Grade 1 through 11 – Specify grade 1 – 11 C

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

12th grade – NO DIPLOMA

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree

e. TRICARE or other military health care
f.

VA (enrolled for VA health care)

g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

FORM D-JA-GE-MI (8-9-2019)

Page 2

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

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

PERIOD OF SERVICE

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

TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.

September 2001 or later

Car, truck, or private van/bus

August 1990 to August 2001 (including Persian Gulf War)

Public van/bus

May 1975 to July 1990

Taxicab

Vietnam Era (August 1964 to April 1975)

Motorcycle

February 1955 to July 1964

Bicycle

Korean War (July 1950 to January 1955)

Walked

January 1947 to June 1950

Plane or seaplane

World War II (December 1941 to December 1946)

Boat, ferry, or water taxi

November 1941 or earlier

Worked from home
Other method

FORM D-JA-GE-MI(8-9-2019)

Page 3

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

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

TYPE OF WORKER

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week

Page 4

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

Draft 9 (08-09-2019)

D-JA-GE-VI

(8-9-2019)

DC

OMB No. 0607-1006: Approval Expires 11/30/2021

U.S. Virgin Islands

INDIVIDUAL CENSUS QUESTIONNAIRE
FLASHCARD

Everyone counts.
The goal of the 2020 Census of the U.S. Virgin Islands is to count everyone by collecting information about all
adults, children, and babies living in the U.S. Virgin Islands.

Census data are important.
The U.S. Constitution requires a census every 10 years. When you respond to the 2020 Census of the U.S.
Virgin Islands, you are doing your part to help your community plan for hospitals and schools, support local
programs, improve emergency services, construct roads, inform businesses looking to add jobs and more.

Taking part is your civic duty.
Completing the 2020 Census of the U.S. Virgin Islands is required. It is a way to say I count.

Your information is confidential.
Federal law protects your responses. Your answers can only be used to produce statistics and cannot be used
against you by any government agency or court.

Use this flashcard to answer questions from the 2020 Census of the
U.S. Virgin Islands.
Please turn to the next page to begin using this flashcard.

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

HISPANIC ORIGIN

Are you of Hispanic, Latino, or Spanish origin?

RACE

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

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

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

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

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

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

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

Some other race – Print race or origin. C

FORM D-JA-GE-VI (8-9-2019)

Page 1

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

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

HEALTH INSURANCE

HIGHEST DEGREE or LEVEL OF SCHOOL

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

Are you CURRENTLY covered by any of the following types
of health insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of coverage in items a – h.

NO SCHOOLING COMPLETED
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten
Kindergarten

Yes

No

a. Insurance through a current or former employer
or union (of yours or another family member)
b. Insurance purchased directly from an insurance
company (by you or another family member)

Grade 1 through 11 – Specify grade 1 – 11 C

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

12th grade – NO DIPLOMA

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree

e. TRICARE or other military health care
f.

VA (enrolled for VA health care)

g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C

Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

FORM D-JA-GE-VI (8-9-2019)

Page 2

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

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

PERIOD OF SERVICE

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

TRANSPORTATION TO WORK

How did you usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.

September 2001 or later

Car, truck, or private van/bus

August 1990 to August 2001 (including Persian Gulf War)

Public van/bus

May 1975 to July 1990

Taxicab

Vietnam Era (August 1964 to April 1975)

Motorcycle

February 1955 to July 1964

Bicycle

Korean War (July 1950 to January 1955)

Walked

January 1947 to June 1950

Plane or seaplane

World War II (December 1941 to December 1946)

Boat, ferry, or water taxi

November 1941 or earlier

Worked from home
Other method

FORM D-JA-GE-VI (8-9-2019)

Page 3

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

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

TYPE OF WORKER

Which one of the following best describes your
employment last week or the most recent employment in
the past 5 years (since 2015)? Mark I
K ONE box.
J
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including tax-exempt and charitable
organizations)
GOVERNMENT EMPLOYEE
Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional practice,
or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-profit family business or farm
for 15 hours or more per week

Page 4

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

Draft 9 (08-09-2019)

D-JA-GE-VI(S)

(8-9-2019)

DC

Núm. de OMB 0607-1006: Aprobado hasta 11/30/2021

U.S. Virgin Islands

TARJETA DE REFERENCIA PARA EL
CUESTIONARIO INDIVIDUAL DEL CENSO

Todos cuentan.
El objetivo del Censo del 2020 de las Islas Vírgenes de los EE. UU. es contar a todos mediante la recopilación de
información sobre adultos, niños y bebés que vivan en las Islas Vírgenes de los EE. UU.

Los datos del censo son importantes.
La Constitución de los EE. UU. requiere un censo cada 10 años. Cuando usted responde al Censo del 2020 de
las Islas Vírgenes de los EE. UU., está haciendo su parte para ayudar a su comunidad a planificar para
hospitales y escuelas, apoyar programas locales, mejorar servicios de emergencia, construir caminos, informar a
las empresas que desean agregar puestos de trabajo y más.

Participar es su deber cívico.
Completar el Censo del 2020 de las Islas Vírgenes de los EE. UU. es obligatorio. Es una manera de decir
"Yo cuento".

Su información es confidencial.
La ley federal protege sus respuestas. Sus respuestas se pueden usar solo para producir estadísticas y no
pueden ser usadas en su contra por ninguna agencia del gobierno o tribunal.

Use esta tarjeta de referencia para responder preguntas del Censo del 2020 de las
Islas Vírgenes de los EE. UU.
Por favor, dé vuelta a la siguiente página para comenzar a usar esta tarjeta de referencia.

D-JA-GE-VI(S) - Base prints Black Ink

ORIGEN HISPANO

¿Es usted de origen hispano, latino o español?

RAZA

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

No, no de origen hispano, latino o español
Sí, mexicano, mexicanoamericano, chicano

Blanca – Escriba, por ejemplo, alemán, irlandés, inglés, italiano,
libanés, egipcio, etc. C

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

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

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

China

Vietnamita

Nativa de Hawái

Filipina

Coreana

Samoana

India asiática

Japonesa

Chamorra

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

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

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

FORM D-JA-GE-VI(S) (8-9-2019)

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SEGURO MÉDICO

TÍTULO o NIVEL DE EDUCACIÓN MÁS ALTO

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

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

NO HA COMPLETADO NINGÚN GRADO
No ha completado ningún grado
GUARDERÍA O PREESCOLAR HASTA GRADO 12
Guardería, preescolar o prekindergarten
Kindergarten
Grado 1 al 11 – Especifique el grado, 1 - 11 C

Grado 12 – SIN DIPLOMA
GRADUADO(A) DE ESCUELA SECUNDARIA O PREPARATORIA
(HIGH SCHOOL)
Diploma de escuela secundaria o preparatoria (high school)
GED o examen equivalente
UNIVERSIDAD O ALGUNOS CRÉDITOS UNIVERSITARIOS
Algunos créditos universitarios, pero menos de 1 año de
créditos universitarios
1 año o más de créditos universitarios, sin título
Título asociado universitario (por ejemplo: AA, AS)

No

a. Seguro a través de su empleador o sindicato
(union), actual o previo (suyo o de cualquier
otro miembro de la familia)
b. Seguro adquirido directamente de una compañía
de seguro (por usted o por cualquier
otro miembro de la familia)
c. Medicare, para personas que tienen 65 años o
más, o personas con ciertas discapacidades
d. Medicaid, Medical Assistance o cualquier tipo de
plan de asistencia gubernamental para personas
con bajos ingresos o con discapacidades
e. TRICARE u otro seguro de salud militar
f.

Administración de Veteranos (VA) (inscrito[a] en
el sistema de cuidado de salud militar de la VA)

g. Servicio de Salud Indio (Indian Health Service)
h. Cualquier otro tipo de seguro de salud o plan
de cobertura de salud – Especifique C

Título de licenciatura universitaria (por ejemplo: BA, BS)
DESPUÉS DEL TÍTULO DE LICENCIATURA UNIVERSITARIA
Título de maestría (por ejemplo: MA, MS, MEng, MEd, MSW, MBA)
Título profesional más allá de un título de licenciatura
universitaria (por ejemplo: MD, DDS, DVM, LLB, JD)
Título de doctorado (por ejemplo: PhD, EdD)
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TRANSPORTE AL TRABAJO

PERÍODO DE SERVICIO

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

¿Cómo llegó usted habitualmente al trabajo LA SEMANA PASADA?
Marque I
K UNA casilla para el medio de transporte que utilizó por
J
más distancia.

Septiembre del 2001 o después

Automóvil, camión o van/autobús privado

Agosto del 1990 a agosto del 2001 (incluyendo la Guerra del
Golfo Pérsico)

Van/autobús público
Taxi

Mayo del 1975 a julio del 1990
Motocicleta
Época de Vietnam (agosto del 1964 a abril del 1975)
Bicicleta
Febrero del 1955 a julio del 1964
Caminó
Guerra de Corea (julio del 1950 a enero del 1955)

Avión o hidroavión

Enero del 1947 a junio del 1950
Lancha, ferri o taxi acuático
Segunda Guerra Mundial (diciembre del 1941 a diciembre
del 1946)

Trabajó en el hogar

Noviembre del 1941 o antes

Otro método

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TIPO DE TRABAJADOR

¿Cuál de las siguientes opciones describe mejor su empleo la
semana pasada o el empleo más reciente en los últimos cinco
años (desde 2015)? Marque I
K UNA casilla.
J
EMPLEADO(A) DEL SECTOR PRIVADO
Empresa u organización con fines de lucro
Organización sin fines de lucro (incluyendo organizaciones
exentas de impuestos y organizaciones benéficas)
EMPLEADO(A) DEL GOBIERNO
Gobierno local o territorial
(por ejemplo: escuela primaria pública)
Servicio activo en las Fuerzas Armadas de EE. UU.
o en los Cuerpos Comisionados
Empleado(a) civil del gobierno federal
EMPLEADO(A) POR CUENTA PROPIA U OTRO
Propietario(a) de un negocio, práctica profesional o finca
no incorporados
Propietario(a) de un negocio, práctica profesional o finca
incorporados
Trabajó sin paga en un negocio o finca de la familia con
fines de lucro 15 horas o más por semana

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