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pdfRequest for Non-Substantive Change to the American Community Survey (ACS)
OMB Control No. 0607-0810
U.S. Department of Commerce
U.S. Census Bureau
The American Community Survey (ACS) mails survey materials to about 287,000 HU addresses
each month. The mailing operations are conducted through the U.S. Postal Service and use
first-class postage rates for all pieces. For addresses that were mailed survey materials but did
not respond by mail, internet, or by calling the telephone questionnaire assistance line, the
Census Bureau selects a subsample of all households and assign them to the CAPI (nonresponse
follow-up) data collection mode. Unmailable household addresses are sampled and included in
the CAPI data collection mode.
In 2017, the HU sample yielded approximately 135,000 self-response interviews. The HU CAPI
follow-up yielded an estimated response rate of approximately 87 percent in 2017. The 2017
final weighted response rate for ACS was 94 percent.
On June 7, 2019, the Office of Management and Budget (OMB) approved the American
Community Survey (0607-0810) information collection. The current collection will expire on
June 30, 2022. This non-substantive change request includes updates to the Year Structure Built
response options, respondent letters used during the Computer Assisted Personal Interviewing
operation, and modifications to the fifth mailing in the self-response operation.
In addition, on March 18, 2020, the U.S. Census Bureau announced a two-week suspension of
2020 Census field operations to help protect the American public and our employees from the
coronavirus outbreak. (Press release is available here: https://2020census.gov/en/newsevents/press-releases/jeffersonville-statement.html) On the same day, the Census Bureau also
made temporary adjustments to operations at two Census Bureau facilities in Jeffersonville,
Indiana: the National Processing Center and Paper Data Capture Center East. Until April 1, 2020,
these two facilities will transition to the minimum number of on-site staff necessary to continue
operations. After April 1, 2020, it is likely that NPC will continue with minimal operations due to
staff absences because of the COVID-19 guidance for federal employees.
Operations, including printing, assembly, mail out, and data capture, for the ACS are already
experiencing negative impacts because of this reduction in operations and the significant
shortages of available staff. Therefore, it is likely that the ACS program will need to adapt the
respondent contact strategy for the ACS to ensure continued high response rates and to lessen
the effects on data quality. The Census Bureau plans to engage regularly with OMB on any
implementation changes to the respondent contact strategy for ACS and will document changes
implemented through a nonsubstantive change request once every month for the effected time
period.
1
Year Structure Built (ACS-1)
We are proposing to modify the Year Structure Built response options for the 2021 American
Community Survey (ACS) and the Puerto Rico Community Survey (PRCS). Adding new response
categories makes the options more current and have more years as a check box option.
Currently, the response options are as follows:
About when was this building first built?
□ 2000 or later - Specific year □ 1990 to 1999
□ 1980 to 1989
□ 1970 to 1979
□ 1960 to 1969
□ 1950 to 1959
□ 1940 to 1949
□ 1939 or earlier
The proposed change is as follows:
About when was this building first built?
□ 2020 or later - Specific year □ 2010 to 2019
□ 2000 to 2010
□ 1990 to 1999
□ 1980 to 1989
□ 1970 to 1979
□ 1960 to 1969
□ 1950 to 1959
□ 1940 to 1949
□ 1939 or earlier
2
Respondent Letters
The final mode of data collection is computer-assisted personal interviewing (CAPI) and is used
to conduct personal interviews for a sample of addresses for which the Census Bureau has not
obtained a self-response (paper or internet). The CAPI interviewers have several tools available
to explain the ACS to households, including an introductory letter, a thank you letter,
brochures, and letters for reluctant CAPI respondents.
We are proposing to include letters to provide more information to respondents, such as how
to respond to the online instrument, information to better understand the benefit and value of
the data being collected, information to respondents who the field representative have not
been able to contact, and a final attempt letter to encourage participation.
The letter describing how to respond to the survey online is available in English, with a version
for each of the six Regional Offices (ROs). The no one home letter is available in English,
Spanish, Chinese, Korean, Russian, and Vietnamese, with two versions, one for households with
a mailing address and one for households with no mailing address (NMB). The better
understanding letter is available in English, Spanish, Chinese, Korean, Russian, and Vietnamese.
The final attempt letter is available in English. These letters are included in Attachment V.
Fifth Mailing (ACS-23)
As part of the October 2019 ACS panel, the Census Bureau conducted the 2019 ACS Due Dates
Test (OMB Control Number: 0607-0936). The test was designed to determine if including a due
date in the fifth mailing increases self-response rates. The current mailing does not contain an
explicit due date but does encourage quick response. A message on the address-side of the
mailer tells respondents to “Respond Now” and in the letter tells the respondent that “...now is
the time to respond.”
The due date is designed to create a sense of urgency, communicate the importance of the
survey, and provide a timeframe for response (which may be beneficial, for example, to those
with a busy schedule). Research has shown that when a request has a sense of urgency, people
are more likely to comply with the request (Kotter, 2008; Gunelius, 2009).
Initial results of the 2019 ACS Due Dates Test indicate that adding an explicit due date in the
fifth mailing increased self-response return rates by about 1.5 percentage points prior to the
start of Computer-Assisted Personal Interviewing (CAPI). For this test, the due date was set 10
days after the respondent was mailed the fifth letter and about 8 days prior to the start of CAPI.
The due date used in production ACS would mirror the timing tested, but may vary month to
month based on the data collection schedule.
3
The updated version of the letter contains the due date in three elements (with an example due
date from the October 2019 panel):
•
A call-out box in the letter:
•
Text in the letter after the call-out box that reads:
“Because your response is critically important to your local community and to your
country, a Census Bureau interviewer may come to your home to complete the survey
in person. Respond by November 22, 2019 to be removed from our schedule for a
visit.”
•
A box on the address-side of the pressure seal mailer:
See Attachment VI for a copy of the updated fifth mailing.
Burden
There is no change to the burden to the public associated with these changes.
The following materials are attached:
I.
Paper questionnaire (ACS-1)
II.
Internet Data Collection application (ACS-400C)
III.
Failed-edit Follow-up instrument (HU Failed Edit Follow Up Qts)
IV.
Telephone Questionnaire Assistance / Housing Unit Personal Interview instrument (HU
CAPI-TQA DY21 YBL Updates)
V.
Respondent Letters
o Internet Letter
o Better Understanding Letter (ACS-613BUL)
o No One Home Letter (ACS-613NOH)
o No One Home Letter (ACS-613NOH-NMB)
o ACS Final Attempt Letter
VI.
Fifth Mailing (ACS-23)
4
Attachment I: Paper Questionnaire
(ACS-1)
13190012
DC
The American Community Survey
Start Here
You have two ways to respond:
➜
Respond online today at:
https://respond.census.gov/acs
Please print the name and telephone number of the
person who is filling out this form. We will only
contact you if needed for official Census Bureau business.
Last Name
OR
First Name
Complete this form and mail it
back as soon as possible.
Area Code + Number
Your response is required by law.
The American Community Survey is
conducted by the U.S. Census Bureau.
This survey is one of only a few
surveys for which all recipients are
required by law to respond. The
U.S. Census Bureau is required by
law to protect your information.
MI
—
➜
How many people are living or staying at this address?
• INCLUDE everyone who is living or staying here for more
than 2 months.
• INCLUDE yourself if you are living here for more than 2
months.
• INCLUDE anyone else staying here who does not have
another place to stay, even if they are here for 2 months or
less.
If you need help or have
questions about completing
this form, please call
1-800-354-7271.
• DO NOT INCLUDE anyone who is living somewhere else for
more than 2 months, such as a college student living away or
someone in the Armed Forces on deployment.
Number of people
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330.
¿NECESITA AYUDA? Llame sin cargo
alguno al 1-877-833-5625.
For more information about the American
Community Survey, visit our website at:
https://www.census.gov/acs
➜
Fill out pages 2 – 7 for everyone, including yourself,
who is living or staying at this address for more
than 2 months. Then complete the rest of the form.
ACS-1(2020)
FORM
(07-13-2019)
§.4!-¤
OMB No. 0607-0810
OMB No. 0607-0936
13190020
Person 1
(Person 1 is the person living or staying here in whose
name this house or apartment is owned, being bought,
or rented. If there is no such person, start with the name
of any adult living or staying here.)
➜
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
5
Is Person 1 of Hispanic, Latino, or Spanish origin?
Please print today’s date.
No, not of Hispanic, Latino, or Spanish origin
Month
Yes, Mexican, Mexican Am., Chicano
Day
Year
Yes, Puerto Rican
Yes, Cuban
1
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
What is Person 1’s name?
Last Name (Please print)
First Name
2
What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
How is this person related to Person 1?
Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
What is Person 1’s sex? Mark (X) ONE box.
Male
4
6
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
X
3
MI
Female
What is Person 1’s age and what is Person 1’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
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
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Some other race – Print race or origin. C
§.4!5¤
2
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13190038
Person 2
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 2’s name?
Last Name (Please print)
Is Person 2 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 2’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 2’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 2’s age and what is Person 2’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.4!G¤
3
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13190046
Person 3
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 3’s name?
Last Name (Please print)
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 3’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 3’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 3’s age and what is Person 3’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.4!O¤
4
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13190053
Person 4
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 4’s name?
Last Name (Please print)
Is Person 4 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 4’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 4’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 4’s age and what is Person 4’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.4!V¤
5
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13190061
Person 5
➜ NOTE: Please answer BOTH Question 5 about
Hispanic origin and Question 6 about race. For this
survey, Hispanic origins are not races.
1
5
What is Person 5’s name?
Last Name (Please print)
Is Person 5 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
First Name
Yes, Puerto Rican
MI
Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Print,
for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc. C
How is this person related to Person 1?
Mark (X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
6
Same-sex husband/wife/spouse
What is Person 5’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
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
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roommate or housemate
3
Foster child
Chinese
Vietnamese
Native Hawaiian
Other nonrelative
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Other Asian –
Print, for example,
Pakistani,
Cambodian,
Hmong, etc. C
Female
What is Person 5’s age and what is Person 5’s
date of birth? For babies less than 1 year old, do not
write the age in months. Write 0 as the age.
Print numbers in boxes.
Age (in years)
Month
Day
Year of birth
Some other race – Print race or origin. C
§.4!^¤
6
Other Pacific
Islander – Print,
for example,
Tongan, Fijian,
Marshallese, etc. C
13190079
➜
If there are more than five people living or staying here, print their names in the spaces for Person 6
through Person 12. We may call you for more information about them. C
Person 6
Last Name (Please print)
Sex
Male
Female
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
First Name
MI
Age (in years)
Person 7
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 8
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 9
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 10
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 11
Last Name (Please print)
Sex
Male
Female
Age (in years)
Person 12
Last Name (Please print)
Sex
Male
Female
§.4!p¤
Age (in years)
7
13190087
Housing
➜
Please answer the following questions about
the house, apartment, or mobile home at the
address on the mailing label.
1
Which best describes this building?
Include all apartments, flats, etc., even if vacant.
A
Answer 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?
A mobile home
Less than 1 acre ➔ SKIP to question 6a
A one-family house detached from any
other house
1 to 9.9 acres
A one-family house attached to one or
more houses
10 or more acres
A building with 2 apartments
5
A building with 3 or 4 apartments
A building with 5 to 9 apartments
None
A building with 10 to 19 apartments
$1 to $999
A building with 20 to 49 apartments
$1,000 to $2,499
A building with 50 or more apartments
$2,500 to $4,999
Boat, RV, van, etc.
2
$5,000 to $9,999
$10,000 or more
About when was this building first built?
2020 or later – Specify year
IN THE PAST 12 MONTHS, what were the actual
sales of all agricultural products from this
property?
6
2010 to 2019
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.
2000 to 2009
• INCLUDE bedrooms, kitchens, etc.
• EXCLUDE bathrooms, porches, balconies, foyers,
halls, or unfinished basements.
1990 to 1999
Number of rooms
1980 to 1989
1970 to 1979
1960 to 1969
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".
1950 to 1959
1940 to 1949
Number of bedrooms
1939 or earlier
3
When did PERSON 1 (listed on page 2) move into
this house, apartment, or mobile home?
§.4!x¤
8
13190095
Housing (continued)
7
Does this house, apartment, or mobile home
have –
Yes
11 Do you or any member of this household have
access to the Internet using a –
No
a. cellular data plan for a
smartphone or other mobile
device?
a. hot and cold running water?
b. a bathtub or shower?
No
b. broadband (high speed)
Internet service such as cable,
fiber optic, or DSL service
installed in this household?
c. satellite Internet service
installed in this household?
d. dial-up Internet service
installed in this household?
e. some other service?
Specify service C
c. a sink with a faucet?
d. a stove or range?
e. a refrigerator?
8
Yes
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
9
12 How many automobiles, vans, and trucks of
one-ton capacity or less are kept at home for
use by members of this household?
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
None
1
No
a. Desktop or laptop
2
b. Smartphone
3
c. Tablet or other portable
wireless computer
4
5
d. Some other type of computer
Specify C
6 or more
13 Which FUEL is used MOST for heating this
house, apartment, or mobile home?
10 At this house, apartment, or mobile home –
Gas: from underground pipes serving the
neighborhood
do you or any member of this household have
access to the Internet?
Gas: bottled, tank, or LP
Yes, by paying a cell phone company or
Internet service provider
Electricity
Yes, without paying a cell phone company or
Internet service provider ➔ SKIP to question 12
Fuel oil, kerosene, etc.
Coal or coke
No access to the Internet at this house, apartment,
or mobile home ➔ SKIP to question 12
Wood
Solar energy
Other fuel
No fuel used
§.4!¢¤
9
13190103
Housing (continued)
14 a. LAST MONTH, what was the cost of electricity 16 Is this house, apartment, or mobile home part of
for this house, apartment, or mobile home?
a condominium?
Last month’s cost – Dollars
$
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.
.00
,
OR
Monthly amount – Dollars
Included in rent or condominium fee
$
No charge or electricity not used
.00
,
OR
b. LAST MONTH, what was the cost of gas for
this house, apartment, or mobile home?
None
No
Last month’s cost – Dollars
$
.00
,
17 Is this house, apartment, or mobile home –
Mark (X) ONE box.
OR
Owned by you or someone in this household
with a mortgage or loan? Include home equity loans.
Included in rent or condominium fee
Included in electricity payment entered above
Owned by you or someone in this household free
and clear (without a mortgage or loan)?
No charge or gas not used
Rented?
Occupied without payment of rent? ➔ SKIP to
on the next page
c. IN THE PAST 12 MONTHS, what was the cost
of water and sewer for this house, apartment,
or mobile home? If you have lived here less than
12 months, estimate the cost.
Past 12 months’ cost – Dollars
$
B
.00
,
Answer questions 18a and b if this house,
apartment, or mobile home is RENTED.
Otherwise, SKIP to question 19.
OR
Included in rent or condominium fee
18 a. What is the monthly rent for this house,
apartment, or mobile home?
No charge
Monthly amount – Dollars
d. IN THE PAST 12 MONTHS, what was the cost
of oil, coal, kerosene, wood, etc., for this
house, apartment, or mobile home? If you have
lived here less than 12 months, estimate the cost.
$
,
b. Does the monthly rent include any meals?
Past 12 months’ cost – Dollars
Yes
$
.00
,
No
OR
Included in rent or condominium fee
No charge or these fuels not used
15 IN THE PAST 12 MONTHS, did you or any
member of this household receive benefits
from the Food Stamp Program or SNAP (the
Supplemental Nutrition Assistance Program)?
Do NOT include WIC, the School Lunch Program, or
assistance from food banks.
Yes
No
§.4"$¤
.00
10
C
13190111
Housing (continued)
C
c. Does the regular monthly mortgage payment
include payments for real estate taxes on THIS
property?
Answer questions 19 – 23 if you or any member
of this household OWNS or IS BUYING this
house, apartment, or mobile home.
Otherwise, SKIP to E .
Yes, taxes included in mortgage payment
No, taxes paid separately or taxes not required
19 About how much do you think this house and lot,
d. Does the regular monthly mortgage payment
include payments for fire, hazard, or flood
insurance on THIS property?
apartment, or mobile home (and lot, if owned)
would sell for if it were for sale?
Amount – Dollars
Yes, insurance included in mortgage payment
$
,
.00
,
20 What are the annual real estate taxes on THIS
property?
No, insurance paid separately or no insurance
23 a. Do you or any member of this household have
a second mortgage or a home equity loan on
THIS property?
Annual amount – Dollars
$
Yes, home equity loan
.00
,
Yes, second mortgage
OR
Yes, second mortgage and home equity loan
None
No ➔ SKIP to
21 What is the annual payment for fire, hazard, and
b. How much is the regular monthly payment on
all second or junior mortgages and all home
equity loans on THIS property?
flood insurance on THIS property?
Annual amount – Dollars
$
Monthly amount – Dollars
.00
,
D
$
OR
.00
,
None
OR
No regular payment required
22 a. Do you or any member of this household have
a mortgage, deed of trust, contract to
purchase, or similar debt on THIS property?
Yes, mortgage, deed of trust, or similar debt
D
Answer question 24 if this is a MOBILE HOME.
Otherwise, SKIP to E .
Yes, contract to purchase
No ➔ SKIP to question 23a
24 What are the total annual costs for personal
property taxes, site rent, registration fees, and
license fees on THIS mobile home and its site?
Exclude real estate taxes.
b. How much is the regular monthly mortgage
payment on THIS property? Include payment
only on FIRST mortgage or contract to purchase.
Annual costs – Dollars
Monthly amount – Dollars
$
,
$
.00
,
.00
OR
No regular payment required ➔ SKIP to
question 23a
§.4",¤
E
11
Answer questions about PERSON 1 on the next
page. If no one is listed as PERSON 1 on page 2,
SKIP to page 48 for mailing instructions.
13190129
Person 1
➜
Please copy the name of Person 1 from page 2,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
11 What is the highest degree or level of school this
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
Yes, born abroad of U.S. citizen parent or parents
NO SCHOOLING COMPLETED
Yes, U.S. citizen by naturalization – Print year
of naturalization C
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten
No, not a U.S. citizen
9
Grade 1 through 11 – Specify
grade 1 – 11
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.4">¤
12
13190137
Person 1 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
14 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 15a
16 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.
b. What is this language?
a. Insurance through a current or
former employer or union (of this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. How well does this person speak English?
Very well
c. Medicare, for people 65 and older,
or people with certain disabilities
Well
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Not well
Not at all
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
§.4"F¤
13
Yes
No
13190145
Person 1 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
20 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?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer question 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.4"N¤
14
13190152
Person 1 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later
Yes
August 1990 to August 2001 (including
Persian Gulf War)
No ➔ SKIP to question 27
May 1975 to July 1990
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?
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No ➔ SKIP to question 27
January 1947 to June 1950
World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
disability rating?
longest period of time.
Less than 6 months
Yes (such as 0%, 10%, 20%, ... , 100%)
6 to 11 months
No ➔ SKIP to question 30a
1 or 2 years
b. What is this person’s service-connected
disability rating?
3 or 4 years
0 percent
5 or more years
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.4"U¤
15
13190160
Person 1 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
Person(s)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour
Minute
a. Address (Number and street name)
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxicab
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 40a
Ferryboat
Other method
§.4"]¤
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?
Yes ➔ SKIP to question 38
No
16
13190178
Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
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.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city or
county school district)
this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.
State government (including state
colleges/universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (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.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Weeks
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
41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Usual hours worked each WEEK
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)
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§.4"o¤
17
13190186
Person 1 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
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)
$
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
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 and
mark the "No" box for the other person.
No
,
,
TOTAL AMOUNT for past
12 months
$
No
,
,
Loss
No
,
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
,
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.4"w¤
TOTAL AMOUNT for past
12 months
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
,
No
.00
,
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
.00
TOTAL AMOUNT for past
12 months
$
$
44 What was this person’s total income during the
None
Yes ➔
Yes ➔
.00
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
.00
,
g. Retirement income, pensions, survivor or
disability income. 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.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔
$
18
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 48 for mailing instructions.
13190194
Person 2
➜
Please copy the name of Person 2 from page 3,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
11 What is the highest degree or level of school this
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
Yes, born abroad of U.S. citizen parent or parents
NO SCHOOLING COMPLETED
Yes, U.S. citizen by naturalization – Print year
of naturalization C
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten
No, not a U.S. citizen
9
Grade 1 through 11 – Specify
grade 1 – 11
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.4"¡¤
19
13190202
Person 2 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
14 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 15a
16 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.
b. What is this language?
a. Insurance through a current or
former employer or union (of this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. How well does this person speak English?
Very well
c. Medicare, for people 65 and older,
or people with certain disabilities
Well
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Not well
Not at all
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
§.4##¤
20
Yes
No
13190210
Person 2 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
20 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?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer question 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.4#+¤
21
13190228
Person 2 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later
Yes
August 1990 to August 2001 (including
Persian Gulf War)
No ➔ SKIP to question 27
May 1975 to July 1990
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?
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No ➔ SKIP to question 27
January 1947 to June 1950
World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
disability rating?
longest period of time.
Less than 6 months
Yes (such as 0%, 10%, 20%, ... , 100%)
6 to 11 months
No ➔ SKIP to question 30a
1 or 2 years
b. What is this person’s service-connected
disability rating?
3 or 4 years
0 percent
5 or more years
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.4#=¤
22
13190236
Person 2 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
Person(s)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour
Minute
a. Address (Number and street name)
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxicab
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 40a
Ferryboat
Other method
§.4#E¤
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?
Yes ➔ SKIP to question 38
No
23
13190244
Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
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.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city or
county school district)
this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.
State government (including state
colleges/universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (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.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Weeks
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
41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Usual hours worked each WEEK
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)
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§.4#M¤
24
13190251
Person 2 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
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)
$
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
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 and
mark the "No" box for the other person.
No
,
,
TOTAL AMOUNT for past
12 months
$
No
,
,
Loss
No
,
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
,
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.4#T¤
TOTAL AMOUNT for past
12 months
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
,
No
.00
,
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
.00
TOTAL AMOUNT for past
12 months
$
$
44 What was this person’s total income during the
None
Yes ➔
Yes ➔
.00
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
.00
,
g. Retirement income, pensions, survivor or
disability income. 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.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔
$
25
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 48 for mailing instructions.
13190269
Person 3
➜
Please copy the name of Person 3 from page 4,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
11 What is the highest degree or level of school this
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
Yes, born abroad of U.S. citizen parent or parents
NO SCHOOLING COMPLETED
Yes, U.S. citizen by naturalization – Print year
of naturalization C
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten
No, not a U.S. citizen
9
Grade 1 through 11 – Specify
grade 1 – 11
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.4#f¤
26
13190277
Person 3 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
14 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 15a
16 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.
b. What is this language?
a. Insurance through a current or
former employer or union (of this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. How well does this person speak English?
Very well
c. Medicare, for people 65 and older,
or people with certain disabilities
Well
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Not well
Not at all
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
§.4#n¤
27
Yes
No
13190285
Person 3 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
20 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?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer question 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 4 on page 33.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.4#v¤
28
13190293
Person 3 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later
Yes
August 1990 to August 2001 (including
Persian Gulf War)
No ➔ SKIP to question 27
May 1975 to July 1990
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?
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No ➔ SKIP to question 27
January 1947 to June 1950
World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
disability rating?
longest period of time.
Less than 6 months
Yes (such as 0%, 10%, 20%, ... , 100%)
6 to 11 months
No ➔ SKIP to question 30a
1 or 2 years
b. What is this person’s service-connected
disability rating?
3 or 4 years
0 percent
5 or more years
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.4#~¤
29
13190301
Person 3 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
Person(s)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour
Minute
a. Address (Number and street name)
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxicab
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 40a
Ferryboat
Other method
§.4$"¤
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?
Yes ➔ SKIP to question 38
No
30
13190319
Person 3 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
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.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city or
county school district)
this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.
State government (including state
colleges/universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (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.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Weeks
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
41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Usual hours worked each WEEK
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)
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§.4$4¤
31
13190327
Person 3 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
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)
$
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
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 and
mark the "No" box for the other person.
No
,
,
TOTAL AMOUNT for past
12 months
$
No
,
,
Loss
No
,
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
,
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.4$<¤
TOTAL AMOUNT for past
12 months
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
,
No
.00
,
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
.00
TOTAL AMOUNT for past
12 months
$
$
44 What was this person’s total income during the
None
Yes ➔
Yes ➔
.00
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
.00
,
g. Retirement income, pensions, survivor or
disability income. 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.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔
$
32
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 48 for mailing instructions.
13190335
Person 4
➜
Please copy the name of Person 4 from page 5,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
11 What is the highest degree or level of school this
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
Yes, born abroad of U.S. citizen parent or parents
NO SCHOOLING COMPLETED
Yes, U.S. citizen by naturalization – Print year
of naturalization C
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten
No, not a U.S. citizen
9
Grade 1 through 11 – Specify
grade 1 – 11
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.4$D¤
33
13190343
Person 4 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
14 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 15a
16 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.
b. What is this language?
a. Insurance through a current or
former employer or union (of this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. How well does this person speak English?
Very well
c. Medicare, for people 65 and older,
or people with certain disabilities
Well
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Not well
Not at all
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
§.4$L¤
34
Yes
No
13190350
Person 4 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
20 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?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer question 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 5 on page 40.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.4$S¤
35
13190368
Person 4 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later
Yes
August 1990 to August 2001 (including
Persian Gulf War)
No ➔ SKIP to question 27
May 1975 to July 1990
b. Is this grandparent currently responsible for
most of the basic needs of any grandchildren
under the age of 18 who live in this house or
apartment?
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No ➔ SKIP to question 27
January 1947 to June 1950
World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
disability rating?
longest period of time.
Less than 6 months
Yes (such as 0%, 10%, 20%, ... , 100%)
6 to 11 months
No ➔ SKIP to question 30a
1 or 2 years
b. What is this person’s service-connected
disability rating?
3 or 4 years
0 percent
5 or more years
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.4$e¤
36
13190376
Person 4 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
Person(s)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour
Minute
a. Address (Number and street name)
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxicab
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 40a
Ferryboat
Other method
§.4$m¤
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?
Yes ➔ SKIP to question 38
No
37
13190384
Person 4 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
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.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city or
county school district)
this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.
State government (including state
colleges/universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (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.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Weeks
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
41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Usual hours worked each WEEK
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)
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§.4$u¤
38
13190392
Person 4 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
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)
$
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
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 and
mark the "No" box for the other person.
No
,
,
TOTAL AMOUNT for past
12 months
$
No
,
,
Loss
No
,
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
,
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.4$}¤
TOTAL AMOUNT for past
12 months
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
,
No
.00
,
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
.00
TOTAL AMOUNT for past
12 months
$
$
44 What was this person’s total income during the
None
Yes ➔
Yes ➔
.00
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
.00
,
g. Retirement income, pensions, survivor or
disability income. 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.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔
$
39
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 48 for mailing instructions.
13190400
Person 5
➜
Please copy the name of Person 5 from page 6,
then continue answering questions below.
10 a. At any time IN THE LAST 3 MONTHS, has this
person attended school or college? Include only
nursery or preschool, kindergarten, elementary
school, home school, and schooling which leads
to a high school diploma or a college degree.
Last Name
First Name
No, has not attended in the last 3
months ➔ SKIP to question 11
MI
Yes, public school, public college
Yes, private school, private college, home school
7
b. What grade or level was this person attending?
Mark (X) ONE box.
Where was this person born?
In the United States – Print name of state.
Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
College undergraduate years (freshman to senior)
8
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
11 What is the highest degree or level of school this
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
highest degree received.
Yes, born abroad of U.S. citizen parent or parents
NO SCHOOLING COMPLETED
Yes, U.S. citizen by naturalization – Print year
of naturalization C
No schooling completed
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school
Kindergarten
No, not a U.S. citizen
9
Grade 1 through 11 – Specify
grade 1 – 11
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s
degree (for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)
§.4%!¤
40
13190418
Person 5 (continued)
15 a. Did this person live in this house or apartment
F
1 year ago?
Answer question 12 if this person has a bachelor’s
degree or higher. Otherwise, SKIP to question 13.
Person is under 1 year old ➔ SKIP to question 16
Yes, this house ➔ SKIP to question 16
No, outside the United States and Puerto Rico –
Print name of foreign country, or
U.S. Virgin Islands, Guam, etc., below; then SKIP
to question 16
12 This question focuses on this person’s
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
No, different house in the United States or
Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and street name)
13 What is this person’s ancestry or ethnic origin?
Name of city, town, or post office
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or
Puerto Rico
14 a. Does this person speak a language other
ZIP Code
than English at home?
Yes
No ➔ SKIP to question 15a
16 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.
b. What is this language?
a. Insurance through a current or
former employer or union (of this
person or another family member)
For example: Korean, Italian, Spanish, Vietnamese
b. Insurance purchased directly from
an insurance company (by this
person or another family member)
c. How well does this person speak English?
Very well
c. Medicare, for people 65 and older,
or people with certain disabilities
Well
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes
or a disability
Not well
Not at all
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
§.4%3¤
41
Yes
No
13190426
Person 5 (continued)
I
G
Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.
17 a. Is there a premium for this plan? A premium
Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the mailing
instructions on page 48.
20 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?
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such
as prescription costs.
Yes
Yes
No
No ➔ SKIP to question 18a
b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
21 What is this person’s marital status?
Now married
Widowed
Yes
Divorced
No
Separated
18 a. Is this person deaf or does he/she have
Never married ➔ SKIP to
serious difficulty hearing?
J on the next page
Yes
No
22 In the PAST 12 MONTHS did this person get –
Yes
b. Is this person blind or does he/she have
serious difficulty seeing even when wearing
glasses?
No
a. Married?
b. Widowed?
Yes
c. Divorced?
No
23 How many times has this person been married?
H
Answer question 19a – c if this person is 5 years
old or over. Otherwise, SKIP to the mailing
instructions on page 48.
Once
Two times
Three or more times
19 a. Because of a physical, mental, or emotional
condition, does this person have serious
difficulty concentrating, remembering, or
making decisions?
24 In what year did this person last get married?
Year
Yes
No
b. Does this person have serious difficulty
walking or climbing stairs?
Yes
No
c. Does this person have difficulty dressing or
bathing?
Yes
No
§.4%;¤
42
13190434
Person 5 (continued)
27 Has this person ever served on active duty in the
J
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.
Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.
Never served in the military ➔ SKIP to question 30a
Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a
25 In the PAST 12 MONTHS, has this person given
birth to any children?
Now on active duty
On active duty in the past, but not now
Yes
No
28 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
in which this person served, even if just for part of the
period.
26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
September 2001 or later
Yes
August 1990 to August 2001 (including
Persian Gulf War)
No ➔ SKIP to question 27
May 1975 to July 1990
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?
Vietnam era (August 1964 to April 1975)
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No ➔ SKIP to question 27
January 1947 to June 1950
World War II (December 1941 to December 1946)
c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
November 1941 or earlier
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
29 a. Does this person have a VA service-connected
disability rating?
longest period of time.
Less than 6 months
Yes (such as 0%, 10%, 20%, ... , 100%)
6 to 11 months
No ➔ SKIP to question 30a
1 or 2 years
b. What is this person’s service-connected
disability rating?
3 or 4 years
0 percent
5 or more years
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher
§.4%C¤
43
13190442
Person 5 (continued)
30 a. LAST WEEK, did this person work for pay at a
job (or business)?
K
Yes ➔ SKIP to question 31
Answer question 33 if you marked "Car, truck,
or van" in question 32. Otherwise, SKIP to
question 34.
No – Did not work (or retired)
33 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work for
pay, even for as little as one hour?
Person(s)
Yes
No ➔ SKIP to question 36a
31 At what location did this person work LAST
WEEK? If this person worked at more than one
location, print where he or she worked most last
week.
34 LAST WEEK, what time did this person’s trip to
work usually begin?
Hour
Minute
a. Address (Number and street name)
If the exact address is not known, give a description
of the location such as the building name or the
nearest street or intersection.
:
a.m.
p.m.
35 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. Name of city, town, or post office
c. Is the work location inside the limits of that
city or town?
L
Yes
Answer questions 36 – 39 if this person
did NOT work last week. Otherwise, SKIP to
question 40a.
No, outside the city/town limits
36 a. LAST WEEK, was this person on layoff from
d. Name of county
a job?
Yes ➔ SKIP to question 36c
No
e. Name of U.S. state or foreign country
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 39
f. ZIP Code
No ➔ SKIP to question 37
32 How did this person usually get to work LAST
WEEK? Mark (X) ONE box for the method of
transportation used for most of the distance.
Car, truck, or van
Taxicab
Bus
Motorcycle
Subway or elevated rail
Bicycle
Long-distance train or
commuter rail
Walked
Light rail, streetcar,
or trolley
Worked from
home ➔ SKIP
to question 40a
Ferryboat
Other method
§.4%K¤
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?
Yes ➔ SKIP to question 38
No
44
13190459
Person 5 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
M
Answer questions 42a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 43.
Yes
No ➔ SKIP to question 39
42 DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment this person had last week.
38 LAST WEEK, could this person have started a job
if offered one, or returned to work if recalled?
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.
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)
a. Which one of the following best describes this
person’s employment last week or the most
recent employment in the past 5 years?
Mark (X) ONE box.
39 When did this person last work, even for a
few days?
PRIVATE SECTOR EMPLOYEE
Within the past 12 months
1 to 5 years ago ➔ SKIP to
For-profit company or organization
M
Non-profit organization (including
tax-exempt and charitable organizations)
Over 5 years ago or never worked ➔ SKIP to
question 43
GOVERNMENT EMPLOYEE
40 a. During the PAST 12 MONTHS (52 weeks), did
Local government (for example: city or
county school district)
this person work EVERY week? Count
paid vacation, paid sick leave, and military
service as work.
State government (including state
colleges/universities)
Yes ➔ SKIP to question 41
Active duty U.S. Armed Forces or
Commissioned Corps
No
Federal government civilian employee
b. During the PAST 12 MONTHS (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.
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Weeks
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
41 During the PAST 12 MONTHS, in the WEEKS
WORKED, how many hours did this person
usually work each WEEK?
b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?
Usual hours worked each WEEK
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)
d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
§.4%\¤
45
13190467
Person 5 (continued)
d. Social Security or Railroad Retirement.
e. What was this person’s main occupation?
(For example: 4th grade teacher, entry-level plumber)
Yes ➔
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)
$
.00
,
TOTAL AMOUNT for past
12 months
e. Supplemental Security Income (SSI).
Yes ➔
No
$
.00
,
TOTAL AMOUNT for past
12 months
f. Any public assistance or welfare payments
from the state or local welfare office.
43 INCOME IN THE PAST 12 MONTHS
Yes ➔
Mark (X) the "Yes" box for each type of income this
person received, and give your best estimate of the
TOTAL AMOUNT during the PAST 12 MONTHS.
(NOTE: The "past 12 months" is the period from
today’s date one year ago up through today.)
No
If net income was a loss, mark the "Loss" box to the
right of the dollar amount.
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 and
mark the "No" box for the other person.
No
,
,
TOTAL AMOUNT for past
12 months
$
No
,
,
Loss
No
,
Yes ➔
$
No
TOTAL AMOUNT for past
12 months
.00
,
$
,
,
TOTAL AMOUNT for past
12 months
.00
Loss
.00
TOTAL AMOUNT for past
12 months
Loss
➜
§.4%d¤
TOTAL AMOUNT for past
12 months
OR
c. Interest, dividends, net rental income, royalty
income, or income from estates and trusts.
Report even small amounts credited to an account.
,
No
.00
,
PAST 12 MONTHS? Add entries in questions 43a to
43h; subtract any losses. If net income was a loss, enter
the amount and mark (X) the "Loss" box next to the
dollar amount.
.00
TOTAL AMOUNT for past
12 months
$
$
44 What was this person’s total income during the
None
Yes ➔
Yes ➔
.00
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report
NET income after business expenses.
Yes ➔
TOTAL AMOUNT for past
12 months
h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support or
alimony. Do NOT include lump sum payments such
as money from an inheritance or the sale of a home.
a. Wages, salary, commissions, bonuses, or tips
from all jobs. Report amount before deductions for
taxes, bonds, dues, or other items.
$
.00
,
g. Retirement income, pensions, survivor or
disability income. 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.
Mark (X) the "No" box to show types of income
NOT received.
Yes ➔
$
46
Now continue with the mailing instructions
on page 48.
13190475
Page 47 is intentionally
left blank
§.4%l¤
47
13190483
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the
questions on pages 2 – 7
• answered all Housing questions
• answered all Person questions for each
person
➜ Then...
• put the completed questionnaire into the
postage-paid return envelope. If the
envelope has been misplaced, please
mail the questionnaire to:
U.S. Census Bureau
P.O. Box 5240
Jeffersonville, IN 47199-5240
• make sure the barcode above your
address shows in the window of the
return envelope
Thank you for participating in
the American Community Survey.
For Census Bureau Use
POP
EDIT CLERK
EDIT
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to: Paperwork Project, U.S. Census Bureau,
4600 Silver Hill Road, ADDC – 4H277,
Washington, D.C. 20233. You may e-mail comments to
[email protected]; use "Paperwork Project" as the
subject. Please DO NOT RETURN your questionnaire
to this address. Use the enclosed preaddressed
envelope to return your completed questionnaire.
Respondents are not required to respond to any
information collection unless it displays a valid
approval number from the Office of Management
and Budget. This 8-digit number appears in the
bottom right on the front cover of this form.
Form ACS-1(2020) (07-13-2019)
§.4%t¤
48
Attachment II: Internet Data Collection
application (ACS-400C)
ACS-400C
January 2020
American Community Survey
Internet Data Collection Instrument Screen Capture Guide
2020
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
yearbuilt
-
New response categories for internet screen ‘yearbuilt’ will be as follows:
About when was this building first built?
□ 2020 or later - Specific year ______ (4 digits)
□ 2010 to 2019
□ 2000 to 2010
□ 1990 to 1999
□ 1980 to 1989
□ 1970 to 1979
□ 1960 to 1969
□ 1950 to 1959
□ 1940 to 1949
□ 1939 or earlier
Return to Top
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
yearbuilt help
Return to Top
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
Return to Top
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
yearbuilt arrow and highlighting
- ‘yearbuilt’ arrow and highlighting will now be listed under ‘2020 or later – Specific year’ answer category
Return to Top
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
yearbuilt edit message
-‘yearbuilt’ edit message will now appear when specific year entered does not equal a value in range [2020-current year]
- ‘yearbuilt’ edit message update will say “between 2020 and [current year]”
Return to Top
ACS-400C (January 2020)
ACS Internet Screen Capture Guide
Return to Top
Attachment III: Failed-edit Follow-up
instrument (HU Failed Edit Follow Up Qts)
If RAC is <20>:
What is that other Asian group?
(For example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.)
If RAC is <24>:
What is that other Pacific Islander group?
(For example, Fijian, Tongan, and so on.)
If RAC is <20> and <24>
What is that other Asian group and other Pacific Islander group?
(For example, Hmong, Laotian, Thai, Pakistani, Cambodian, Fijan, Tongan, and so on.)
FEFU Screen Name: RCW3
What is {his/her/’s/your} other race group?
Paper Questionnaire Item Number: Housing 2
FEFU Screen Name: YBL
About when was this first built?
(If you do not know exact year, give your best estimate.)
♢ If the building was built in the year 2020 or later, enter <1> and enter the specific year on
the following screen.
❍ 1. 2020 or later
❍ 2. 2010 to 2019
❍ 3. 2000 to 2009
❍ 4. 1990 to 1999
❍ 5. 1980 to 1989
7
❍ 6. 1970 to 1979
❍ 7. 1960 to 1969
❍ 8. 1950 to 1959
❍ 9. 1940 to 1949
❍ 10. 1939 or earlier
FEFU Screen Name: YBLW
(What year was this built?)
♢ Enter specific year was built if 2020 or later.
Paper Questionnaire Item Number: Housing 3
FEFU Screen Name: MVM
When did (you/) move into this ?
♢ Select month
FEFU Screen Name: MVY
When did (you/) move into this ?
♢ Enter the year the household moved into this (mobile home/ house/ apartment/ unit).
Paper Questionnaire Item Number: Housing 7a
FEFU Screen Name: RWATPR (Puerto Rico Only)
Does this have running water?
Paper Questionnaire Item Number: Housing 7b
FEFU Screen Name: HOTWAT (Puerto Rico Only)
Does this have a water heater?
Paper Questionnaire Item Number: Housing 8
8
Attachment IV: Telephone Questionnaire
Assistance / Housing Unit Personal Interview
instrument (HU CAPI-TQA DY21 YBL Updates)
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
COVER SHEET
Housing Part A
Blaise Item-Level Specifications Report
Last Modified: Monday, November 25, 2019
Page 1 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
YBL
Field
Section3.Housing Part A.YBL
Description: Year Built
Form Pane Label: Year Built
SAS Name:
Tag Name:
Inherited Universe:
Universe: If USTAT = 0, 1 or 2
Universe Description: Date Type of Building was built
Help Screen: H_YBL
Question Text: About when was this ^F_BUILDING_TYPE first built?
If the building was built in the year 2020 or later, enter <1> and enter the specific
year on the following screen.
Fills: F_BUILDING_TYPE
Instructions: If (BLD=1) OR (BLDA=1), set FILL BUILDING TYPE = "mobile home"
If (BLD=2, 3) OR (BLDA=2), set FILL BUILDING TYPE = "house"
If BLD=4-9, (OR BLDA=3), set FILL BUILDING TYPE = "apartment"
If BLD=10, D, R, (OR BLDA=4,D,R), set FILL BUILDING TYPE = "unit"
Type: Enumerated
Length: 1
Answer List: T_YBL
Value:
Mnemonic:
Description:
1
2020 or later
2
2010-2019
3
2000-2009
4
1990-1999
5
1980-1989
6
1970-1979
7
1960-1969
8
1950-1959
Last Modified: Monday, November 25, 2019
Page 2 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
9
1940-1949
10
1939 or earlier
x Don't Know
x Refuse
Empty
On Input
x On Output
Array:
Skip Instructions: <1> [go to YBL1>
<2-8,D,R>
If USTAT=2 [go to MVY]
If USTAT=0,1and (BLD=1,2,3 or BLDA=1,2) [go to ACR]
If USTAT=0,1and (BLD=4-9 or BLDA=3) [go to EFFIC]
If USTAT=0,1and (BLD=10,D,R or BLDA=4,D,R) [go to RMS]
Last Modified: Thursday, November 21, 2019
Page 3 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
YBL1
Field
Section3.Housing Part A.YBL1
Description: Specific Year Built
Form Pane Label: Specific Year Built
SAS Name:
Tag Name:
Inherited Universe:
Universe: If USTAT = 0, 1 or 2
AND YBL=1
Universe Description: Specific year building was built
Help Screen: H_YBL1
Question Text: (What year was this ^F_BUILDING_TYPE built?)
Enter specific year ^F_BUILDING_TYPE was built if 2020 or later
Fills: F_BUILDING_TYPE
Instructions: If (BLD=1) OR (BLDA=1), set FILL BUILDING TYPE = "mobile home"
If (BLD=2, 3) OR (BLDA=2), set FILL BUILDING TYPE = "house"
If BLD=4-9, (OR BLDA=3), set FILL BUILDING TYPE = "apartment"
If BLD=10, D, R, (OR BLDA=4,D,R), set FILL BUILDING TYPE = "unit"
Type: String
Length: 4
x Don't Know
x Refuse
Empty
On Input
x On Output
Array:
Skip Instructions: <2020 - Current Year,D,R>
IF USTAT=2 [go to MVY]
IF USTAT=0,1 AND (BLD=1,2,3 or BLDA=1,2) [go to ACR]
IF USTAT=0,1 AND (BLD=4-9 or BLDA=3) [go to EFFIC]
Last Modified: Thursday, November 21, 2019
Page 4 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
IF USTAT=0,1 AND (BLD=10,D,R or BLDA=4,D,R) [go to RMS]
Last Modified: Thursday, November 21, 2019
Page 5 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
YBL1_HRDCHK
Check
Section3.Housing Part A.YBL1_HRDCHK
Description: IF YBL1 is in the future or before 2020
Inherited Universe:
Universe: IF YBL1 > Current Year
Universe Description:
Text: - Input invalid. Value not in range 2020 to ^F_currentyear.
Check Instructions:
Type: Hard
Fills: F_currentyear
Instructions: fill with the current year
Last Modified: Wednesday, January 8, 2020
Page 6 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
MVY_SFTCHK
Check
Section3.Housing Part A.MVY_SFTCHK
Description: MVY before Year Built
Inherited Universe:
Universe: IF MVY<>(D,R) and ((YBL=1 and YBL1 > MVY) or
(YBL in (2-8,D,R) and MVY < YBL Year))
Universe Description: Moved in before 'YBL Year', defined in the instructions below.
Text: I recorded that this ^F_BUILDING_TYPE was built ^F_YBL_year and you also
reported that ^F_you_HHoldername moved in ^F_MVY. Which is correct?
Check Instructions: YBL Year definition:
If YBL=1 and YBL1 <>D,R, then YBL Year= [YBL1 value]
If YBL=1 and YBL1=D,R, then YBL Year= 2020
if YBL=2, then YBL Year= 2010
if YBL=3, then YBL Year= 2000
if YBL=4, then YBL Year= 1990
if YBL=5, then YBL Year= 1980
if YBL=6, then YBL Year= 1970
if YBL=7, then YBL Year= 1960
if YBL=8, then YBL Year= 1950
if YBL=9, then YBL Year= 1940
if YBL=10, Calculate: Current year -126 = [goto MVY_HRDCHK1]
Type: Soft
Fills: F_BUILDING_TYPE
Instructions: If (BLD=1) OR (BLDA=1), set FILL BUILDING TYPE = "mobile home"
If (BLD=2, 3) OR (BLDA=2), set FILL BUILDING TYPE = "house"
If BLD=4-9, (OR BLDA=3), set FILL BUILDING TYPE = "apartment"
If BLD=10, D, R, (OR BLDA=4,D,R), set FILL BUILDING TYPE = "unit"
Fills: F_YBL_year
Instructions: If YBL=1 and YBL1 <>D,R, then "[YBL1 value]"
If YBL=1 and YBL1=D,R, "in 2020"
if YBL=2, "after 2010"
if YBL=3, "after 2000"
if YBL=4, "after 1990"
if YBL=5, "after 1980"
if YBL=6, "after 1970"
Last Modified: Wednesday, January 8, 2020
Page 7 of 8
Survey: ACS HU CAPI/TQA 2021
Section: Section3.Housing Part A
Blaise Item-Level Specifications Report
Spider Version 1.6.2
if YBL=7, "after 1960"
if YBL=8, "after 1950"
if YBL=9, "after 1940"
if YBL=10, Calculate: Current year -126 = [goto MVY_HRDCHK1]
Fills: F_you_HHoldername
Instructions: If respondent is householder, THEN "you"
If householder is not respondent, THEN "[HHoldername]"
Fills: F_MVY
Instructions: Fill MVY value
Last Modified: Wednesday, January 8, 2020
Page 8 of 8
Attachment V: Respondent Letters
o Internet Letter
o Better Understanding Letter (ACS-613BUL)
o No One Home Letter (ACS-613NOH)
o No One Home Letter (ACS-613NOH-NMB)
o ACS Final Attempt Letter
DC
U.S. Census Bureau
Philadelphia Regional Office
Philadelphia, PA 19106-2320
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
Philadelphia Regional Office
100 South Independence Mall West
Suite 410
Philadelphia, PA 19106-2320
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET PHRO (2020)
DC
U.S. Census Bureau
Atlanta Regional Office
Atlanta, GA 30303-2700
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
Atlanta Regional Office
101 Marietta Street, NW, Suite 3200
Atlanta, GA 30303-2700
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET ATRO (2020)
DC
U.S. Census Bureau
Chicago Regional Office
Oak Brook, IL 60523-1918
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
Chicago Regional Office
1111 W. 22nd Street, Suite 400
Oak Brook, IL 60523-1918
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET CHRO (2020)
DC
U.S. Census Bureau
Denver Regional Office
Lakewood, CO 80235
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
Denver Regional Office
6950 W. Jefferson Avenue, Suite 250
Lakewood, CO 80235
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET DNRO (2020)
DC
U.S. Census Bureau
Los Angeles Regional Office
Burbank, CA 91504
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
Los Angeles Regional Office
2300 West Empire Avenue, Suite 300
Burbank, CA 91504
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET LARO (2020)
DC
U.S. Census Bureau
New York Regional Office
New York, NY 10005-3500
<>
Dear Resident:
A U.S. Census Bureau representative will soon contact you in person to complete the
American Community Survey. You can complete the survey online by going to
https://respond.census.gov/acs and logging on with your user ID: <>
The Census Bureau is conducting this survey under the authority of Title 13, Sections 141, 193,
and 221, of the United States Code. The following is provided to give you an explanation of the
importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results from
this survey may be used to decide where new schools, hospitals, and fire stations are needed.
Survey data are used by federal, state, and local governments to make decisions and to develop
programs that will provide health care, education, and transportation services that affect you and
your community. This survey information also helps communities plan for emergency situations
that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks
through screening of the systems that transmit your data. By law, the Census Bureau can only use
your responses to produce statistics.
A member of our staff will contact you in a few days. Your participation and cooperation are
important to the success of the survey. Your response does make a difference! If you have any
questions, call us at the phone number provided at the bottom of this letter. We will be pleased
to help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Regional Director
Office Phone Number: <>
Control Number: <>
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
New York Regional Office
32 Old Slip, 9th Floor
New York, NY 10005-3500
OFFICIAL BUSINESS
Penalty for Private Use $300
ACS-INET NYRO (2020)
ACS-613B(L)(ENGLISH)
Revised June 2017
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
Dear <>:
Recently, a U.S. Census Bureau representative, <>, contacted you in connection
with the American Community Survey. The Census Bureau is conducting this survey under the
authority of Title 13, Sections 141, 193, and 221, of the United States Code. The following is
provided to give you an explanation of the importance of the survey and the uses of the results.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results
from this survey may be used to decide where new schools, hospitals, and fire stations are
needed. Survey data are used by federal, state, and local governments to make decisions and to
develop programs that will provide health care, education, and transportation services that affect
you and your community. This survey information also helps communities plan for emergency
situations that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from
cybersecurity risks through screening of the systems that transmit your data. By law, the
Census Bureau can only use your responses to produce statistics. We enclosed some published
survey results compiled from other households like yours that participated in this survey.
A member of our staff will contact you again in a few days, or you can contact <>
at <>. Your participation and cooperation are important to the success of the
survey. Your response does make a difference! If you have any questions, call
<>, Program Supervisor, on<>. We will be pleased to
help you. For more information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Program Supervisor
Enclosures
ACS-613B(L)(SPANISH)
Revised September 2017
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
Estimado(a) <>:
Recientemente, un representante de la Oficina del Censo de los EE. UU., <>, se
comunicó con usted en relación con la Encuesta sobre la Comunidad Estadounidense. La
Oficina del Censo realiza esta encuesta en conformidad con las Secciones 141, 193 y 221 del
Título 13 del Código de los Estados Unidos. A continuación, le damos una explicación sobre la
importancia de la encuesta y los usos de los resultados.
La Encuesta sobre la Comunidad Estadounidense contiene preguntas sobre las características del
hogar, incluidos temas como la educación, el empleo y la vivienda. La encuesta genera
información fundamental y actualizada que se usa para satisfacer las necesidades de las
comunidades en todos los Estados Unidos. Por ejemplo, los resultados de esta encuesta pueden
usarse para decidir dónde se necesitan nuevas escuelas, hospitales y estaciones de bomberos.
Los gobiernos federal, estatales y locales usan los datos de la encuesta para tomar decisiones y
desarrollar programas que brindarán servicios de salud, educación y transporte que les afectan a
usted y a su comunidad. Esta información también ayuda a las comunidades a planificar para
lidiar con situaciones de emergencia que puedan afectarles a usted y a sus vecinos.
La Oficina del Censo de los EE. UU. está obligada por ley a mantener confidencial su
información. No se nos permite divulgar sus respuestas de manera que su hogar pudiera ser
identificado. En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética
Federal del 2015, sus datos están protegidos contra los riesgos de seguridad cibernética mediante
los controles aplicados a los sistemas que los transmiten. Por ley, la Oficina del Censo puede
usar sus respuestas solamente para producir estadísticas. Adjuntamos algunos resultados de
encuestas que se han publicado, recopilados de otros hogares como el suyo que participaron en
esta encuesta.
Uno de nuestros empleados se comunicará de nuevo con usted en los próximos días, o usted
puede comunicarse con <> al <>. Su participación y cooperación
son importantes para el éxito de la encuesta. ¡Su respuesta marca la diferencia! Si tiene
preguntas, llame a <>, el supervisor del programa, al
<>. Lo ayudaremos con gusto. Para obtener más información sobre la
Encuesta sobre la Comunidad Estadounidense, visite nuestro sitio web en
http://www.census.gov/acs.
Atentamente,
Supervisor del programa
Documentos adjuntos
ACS-613B(L)(CHINESE)
Revised January 2018
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
尊敬的 <>：
近期，美国人口普查局代表 <> 就美国社区调查事宜联系了您。人口普查局在
美国法典第 13 章第 141、193 和 221 节的授权下进行这项调查。提供以下信息是为了
向您说明调查的重要性及调查结果的使用。
美国社区调查包含关于家庭特征的问题，包括教育、就业和住房等主题。它生成重要、
最新信息，用于满足美国各个社区的需求。例如，本调查的结果可用于决定是否需要新
学校、医院和消防站。联邦、州和地方政府使用调查数据作出决定并制定计划，提供影
响您和您的社区的医疗保健、教育和交通服务。本调查信息还帮助社区为可能影响您和
您的邻居的紧急情况制定计划。
法律要求美国人口普查局将您的信息保密。我们不允许以可能识别此家庭的方式公开发
布您的回复。根据 2015 年联邦网络安全增强法案，我们通过筛查传输您的数据的系统，
消除您的数据的网络安全风险。根据法律，人口普查局只能使用您的回复生成统计数据。
我们附上根据参加本调查的其他家庭（和您的家庭一样）的数据编写而成的某些已公布
的调查结果。
我们的员工将在几天内再次联系您，或者您可拨打电话 <> 联系 <>。
您的参与和合作对调查取得成功很重要。您的回复意义非凡！如果您有任何问题，请拨
打电话 <> 联系项目主管 <>。我们将很高兴向您提供帮
助。有关美国社区调查的详细信息，请访问我们的网站 http://www.census.gov/acs。
此致，
项目主管
附件
ACS-613B(L)(KOREAN)
Revised January 2018
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
<>님께:
최근에 미국 통계청(U.S. Census Bureau) 직원인 <>이(가) 미국 지역사회
설문조사와 관련하여 귀하께 연락을 드렸습니다. 통계청은 미국 연방 법령 제 13 장 141,
193 및 221 조항에 의거하여 본 설문조사를 실시하고 있습니다. 다음 내용은
설문조사의 중요성과 결과의 활용에 대한 설명을 드리고자 제공되었습니다.
미국 지역사회 설문조사는 교육, 고용 및 주택과 같은 주제를 포함하여 가정의 특성과
관련된 질문을 포함하고 있습니다. 질문 내용은 미국 전역에 걸친 지역사회의 필요에
부합하기 위하여 사용되는 매우 중요한 최신 정보를 얻기 위한 것입니다. 예를 들면, 본
설문조사의 결과는 신설 학교, 병원 및 소방서가 어디에 필요한지를 결정하는데 사용될
수 있습니다. 설문조사 자료는 연방, 주 및 지방 정부에서 의사결정을 하고, 여러분과
지역사회에 영향을 미치는 의료 서비스, 교육 및 교통 서비스를 제공하는 프로그램을
개발하기 위해 사용됩니다. 본 설문조사 정보는 또한 귀하 및 귀하의 이웃들에 영향을
미칠 수 있는 긴급 상황에 대한 지역사회 계획에 도움이 됩니다.
미국 통계청은 법률에 따라 귀하의 정보를 기밀로 유지합니다. 저희가 참여 가정을
식별할 수 있는 방법으로 귀하의 답변을 공개적으로 발표하는 것은 허용되지 않습니다.
2015 년 연방 사이버보안 개선 법안에 따라서 데이터를 전송하는 시스템의 검사를
통하여 귀하의 데이터를 사이버 보안 위험으로부터 보호합니다. 법률에 의거하여
통계청에서는 귀하의 응답을 통계 목적으로만 사용할 수 있습니다. 귀하와 마찬가지로
본 설문조사에 참여한 다른 가정으로부터 수집한 일부 설문조사 결과를
첨부하였습니다.
저희 직원이 수 일 내로 귀하께 다시 연락드리거나 전화번호<>로
<>에게 연락하실 수 있습니다. 귀하의 참여와 협조는 성공적인 설문조사를
위해 중요합니다. 귀하의 답변이 변화를 만듭니다! 문의사항이 있으신 경우에는
프로그램 감독관인 <>에게 <>번으로 연락하여
ACS-613B(L)(KOREAN)
Revised January 2018
주십시오. 기쁜 마음으로 여러분을 도와 드릴 것입니다. 미국 지역사회 설문조사에
관한 보다 자세한 정보는 웹사이트 http://www.census.gov/acs 에서 확인하십시오.
감사합니다.
프로그램 감독관
첨부
ACS-613B(L)(RUSSIAN)
Revised January 2018
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
Уважаемый(-ая) <>:
Недавно представитель Бюро переписи США, <>, связался с вами по поводу
Анкетирования населения США по месту жительства. Бюро переписи проводит это
анкетирование в соответствии с пунктом 13, разделов 141, 193 и 221 Кодекса
Соединенных Штатов. В настоящем документе дается разъяснение в отношении
важности этого анкетирования и использования его результатов.
В Анкетировании населения США по месту жительства содержатся вопросы о
характеристиках домохозяйств, включая такие темы, как образование, занятость и жилье.
Оно позволяет получить критически важную и актуальную информацию, которая
используется для удовлетворения потребностей сообществ, проживающих на всей
территории Соединенных Штатов. Например, результаты этого анкетирования могут
быть использованы для определения того, где необходимы новые школы, больницы и
пожарные станции. Данные анкетирования используются федеральными и местными
органами власти для принятия решений и разработки программ, которые будут
предоставлять услуги в области здравоохранения, образования и перевозок, которые
оказывают влияние на вас и ваше сообщество. Информация, полученная в результате
этого анкетирования, также помогает сообществам разрабатывать планы на случай
чрезвычайных ситуаций, которые могут оказать влияние на вас и ваших соседей.
В соответствии с законом Бюро переписи США обязано сохранять конфиденциальность
вашей информации. Нам не разрешается публиковать ваши ответы таким образом, чтобы
можно было идентифицировать конкретное домохозяйство. В соответствии с
Федеральным законом об усилении кибербезопасности от 2015 года ваши данные
защищены от рисков нарушения кибербезопасности посредством скрининга систем,
которые передают ваши данные. По закону Бюро переписи может использовать ваши
ответы только для получения статистических данных. Во вложениях находятся
некоторые опубликованные результаты анкетирования других домохозяйств, подобных
вашему, которые участвовали в этом анкетировании.
Через несколько дней наш сотрудник снова свяжется с вами, или вы сможете связаться с
<>, позвонив по номеру <>. Ваше участие и сотрудничество
очень важны для успешного проведения анкетирования. Ваши ответы действительно
имеют значение! Если у вас есть какие-либо вопросы, звоните >,
руководителю программы, по номеру <>. Мы будем рады помочь вам.
Для получения дополнительной информации об Анкетировании населения США по
месту жительства посетите наш веб-сайт по адресу http://www.census.gov/acs.
С уважением,
руководитель программы
Вложения
ACS-613B(L)(VIETNAMESE)
Revised January 2018
APPROVED BETTER UNDERSTANDING LETTER
<>
<>
<>
<>
Kính gửi <>:
Gần đây, một đại diện của Cục Thống Kê Dân Số, <>, đã liên hệ với quý vị
về cuộc Khảo Sát Cộng Đồng tại Mỹ. Cục Thống Kê Dân Số tiến hành cuộc khảo sát
này theo thẩm quyền của Mục 13, Phần 141, 193 và 221 của Đạo Luật Hoa Kỳ. Phần
sau đây sẽ giải thích cho quý vị về tầm quan trọng của cuộc khảo sát và mục đích sử
dụng các kết quả.
Cuộc Khảo Sát Cộng Đồng tại Mỹ gồm các câu hỏi về đặc điểm hộ gia đình bao gồm
các chủ đề như giáo dục, việc làm và nhà ở. Cuộc khảo sát cung cấp thông tin quan
trọng, cập nhật được sử dụng để đáp ứng nhu cầu của cộng đồng trên toàn Hoa Kỳ.
Ví dụ, kết quả từ cuộc khảo sát có thể được sử dụng để quyết định nơi nào cần trường
học, bệnh viện và trạm cứu hỏa mới. Dữ liệu khảo sát được chính quyền liên bang,
tiểu bang và địa phương sử dụng để ra quyết định và phát triển những chương trình để
cung cấp dịch vụ chăm sóc sức khỏe, giáo dục và giao thông vận tải ảnh hưởng tới
quý vị và cộng đồng của quý vị. Thông tin khảo sát này cũng giúp các cộng đồng lập
kế hoạch cho các tình huống khẩn cấp có thể ảnh hưởng tới quý vị và hàng xóm của
quý vị.
Luật pháp yêu cầu Cục Thống Kê Dân Số Hoa Kỳ giữ bảo mật thông tin của quý vị.
Chúng tôi không được phép công bố công khai phần trả lời của quý vị theo cách thức
có thể xác định hộ gia đình này. Theo Đạo Luật Củng Cố An Ninh Mạng Liên Bang
2015, dữ liệu của quý vị được bảo vệ khỏi các rủi ro an ninh mạng thông qua sàng lọc
các hệ thống truyền tải dữ liệu của quý vị. Theo luật, Cục Thống Kê Dân Số chỉ có thể
sử dụng phần trả lời của quý vị để lập số liệu thống kê. Chúng tôi đính kèm các kết
quả khảo sát đã công bố được thu thập từ những hộ gia đình khác giống quý vị tham
gia vào cuộc khảo sát này.
Một nhân viên của chúng tôi sẽ liên hệ lại với quý vị trong vài ngày tới, hoặc quý vị có
thể liên hệ với <> theo số <>. Sự tham gia và hợp tác của
quý vị rất quan trọng để khảo sát này thành công. Câu trả lời của quý vị thực sự tạo
ra sự khác biệt! Nếu quý vị có bất kỳ thắc mắc nào, xin hãy gọi tới
<>, Giám Sát Viên Chương Trình, theo số<>.
Chúng tôi sẽ sẵn lòng giúp đỡ quý vị. Để biết thêm thông tin về Khảo Sát Cộng Đồng
tại Mỹ, xin hãy truy cập trang web của chúng tôi tại địa chỉ http://www.census.gov/acs.
Trân trọng,
Giám Sát Viên Chương Trình
Tài liệu đính kèm
ACS-613N(L)(ENGLISH)
Revised June 2017
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
Dear <>:
Your address has been selected for participation in the American Community Survey (ACS). A
U.S. Census Bureau representative, <>, recently tried to contact you to complete
the survey. This survey is conducted by the Census Bureau to produce critical, up-to-date
information that is used to meet the needs of communities across the United States. All
information is collected under the authority of Title 13, Sections 141, 193, and 221, of the
United States Code.
The American Community Survey contains questions about your household characteristics
including such topics as education, employment, and housing. These questions are required to
collect data needed to manage or evaluate government programs. The ACS will provide
communities annually updated, detailed information previously available only when the Census
Bureau conducted a census every 10 years.
Because of the importance of the survey, we would appreciate if you would let us know how to
contact you by completing the information at the bottom of this letter and returning it in the
postage paid envelope. You may also call <> at <> or
<>, Program Supervisor, on<>. We will be happy to
arrange an interview at your convenience and conduct the interview as quickly as possible.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from
cybersecurity risks through screening of the systems that transmit your data. By law, the
Census Bureau can only use your responses to produce statistics. Your participation and
cooperation are important to the success of the survey. Thank you for your help. For more
information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Program Supervisor
ACS-613N(L)(ENGLISH)
Revised June 2017
Time when I can usually be reached:
Telephone number where I can usually be reached:
Language Preference:
ACS-613N(L)(SPANISH)
Revised September 2017
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
Estimado(a) <>:
Su dirección fue seleccionada para participar en la Encuesta sobre la Comunidad Estadounidense
(ACS). Un representante de la Oficina del Censo de los EE. UU., <>, intentó
comunicarse con usted recientemente para completar la encuesta. La Oficina del Censo lleva a
cabo esta encuesta a fin de generar información fundamental y actualizada que se usa para
satisfacer las necesidades de las comunidades en todos los Estados Unidos. Toda la información
se recopila en conformidad con la autoridad del Título 13, Secciones 141, 193 y 221 del Código
de los Estados Unidos.
La Encuesta sobre la Comunidad Estadounidense contiene preguntas sobre las características de
su hogar, incluidos temas como la educación, el empleo y la vivienda. Estas preguntas son
necesarias para recopilar datos precisos para gestionar o evaluar programas del gobierno. La
ACS les proporcionará a las comunidades información anual actualizada y detallada que
previamente solo estaba disponible cuando la Oficina del Censo llevaba a cabo el censo cada 10
años.
Debido a la importancia de la encuesta, le agradeceríamos que nos informara cómo
comunicarnos con usted al completar la información que se encuentra al final de esta carta y
devolverla en el sobre con franqueo pagado. También puede comunicarse con <> al
<> o con <>, el supervisor del programa, al
<>. Será un placer concertar una entrevista a su conveniencia y realizarla tan
rápido como sea posible.
La Oficina del Censo de los EE. UU. está obligada por ley a mantener confidencial su
información. No se nos permite divulgar sus respuestas de manera que su hogar pudiera ser
identificado. En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética
Federal del 2015, sus datos están protegidos contra los riesgos de seguridad cibernética mediante
los controles aplicados a los sistemas que los transmiten. Por ley, la Oficina del Censo puede
usar sus respuestas solamente para producir estadísticas. Su participación y cooperación son
importantes para el éxito de la encuesta. Le agradecemos por su ayuda. Para obtener más
información sobre la Encuesta sobre la Comunidad Estadounidense, visite nuestro sitio web en
http://www.census.gov/acs.
Atentamente,
Supervisor del programa
ACS-613N(L)(SPANISH)
Revised September 2017
Hora a la que generalmente me pueden contactar:
Número de teléfono donde generalmente me pueden contactar:
Idioma de preferencia:
ACS-613N(L)(CHINESE)
Revised January 2018
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
尊敬的 <>：
您的地址已被选中参加美国社区调查 (ACS)。美国人口普查局代表 <> 最近试
图联系您以完成调查。本调查由人口普查局执行，以生成重要、最新信息，用于满足美
国各个社区的需求。人口普查局在美国法典第 13 章第 141、193 和 221 节的授权下收
集所有信息。
美国社区调查包含关于家庭特征的问题，包括教育、就业和住房等主题。收集管理或评
估政府计划所需数据必须提出这些问题。ACS 将每年向社区提供最新、详细的信息，以
前只有在人口普查局每隔 10 年进行人口普查时才会提供这些信息。
因为调查的重要性，如果您能够填写本信函底部的信息并用邮资已付信封寄回它来告诉
我们如何联系您，我们将不胜感激。您也可拨打电话 <> 联系 <>，
或拨打 <> 联系项目主管 <>。我们将很乐意安排在您方便
的时间尽快进行面谈。
法律要求美国人口普查局将您的信息保密。我们不允许以可能识别此家庭的方式公开发
布您的回复。根据 2015 年联邦网络安全增强法案，我们通过筛查传输您的数据的系统，
消除您的数据的网络安全风险。根据法律，人口普查局只能使用您的回复生成统计数据。
您的参与和合作对调查取得成功很重要。感谢您的帮助。有关美国社区调查的详细信息，
请访问我们的网站 http://www.census.gov/acs。
此致，
项目主管
ACS-613N(L)(CHINESE)
Revised January 2018
通常可联系到我的时间是：
通常可联系到我的电话号码是：
首选语言：
ACS-613N(L)(KOREAN)
Revised January 2018
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
<>님께:
귀하의 주소는 미국 지역사회 설문조사 (ACS)에 참여하기 위하여 선택되었습니다. 미국
통계청 직원인 <>이(가) 최근에 설문조사 작성을 위하여 귀하께 연락을
시도하였습니다. 본 설문조사는 매우 중요한 최신 정보를 얻기 위해 통계청에 의해서
수행되며, 이 정보는 미국 전역에 걸친 지역사회의 요구에 부합하기 위하여 사용됩니다.
모든 정보는 미국 연방 법령 제13장 141, 193 및 221 조항에 의거하여 수집됩니다.
미국 지역사회 설문조사는 교육, 고용 및 주택과 같은 주제를 포함하여 가정의 특성과
관련된 질문을 포함하고 있습니다. 이러한 질문사항은 정부 프로그램을 관리하거나
평가하기 위해 필요한 정보를 수집하기 위해 요구됩니다. ACS는 통계청이 예전에는
10년 마다 인구조사를 수행했을 경우에만 이용가능한 상세 정보를 매년 갱신해서
지역사회에 제공합니다.
설문조사의 중요성으로 인하여 본 서신의 아래에 있는 정보를 작성하셔서 요금별납
봉투를 이용하여 회신해서 연락 방법을 알려주시면 감사하겠습니다. 또한
<>번으로 <>에게 전화하시거나 프로그램 감독관인
<>에게 <>번으로 전화하실 수 있습니다. 귀하의
편의에 맞추어 인터뷰를 예약하고 가능한 빠른 시간내에 인터뷰를 수행하도록
하겠습니다.
미국 통계청은 법률에 따라 귀하의 정보를 기밀로 유지합니다. 저희가 참여 가정을
식별할 수 있는 방법으로 귀하의 답변을 공개적으로 발표하는 것은 허용되지 않습니다.
2015년 연방 사이버보안 개선 법안에 따라서 데이터를 전송하는 시스템의 검사를
통하여 귀하의 데이터를 사이버 보안 위험으로부터 보호합니다. 법률에 의거하여
통계청에서는 귀하의 응답을 통계 목적으로만 사용할 수 있습니다. 귀하의 참여와
ACS-613N(L)(KOREAN)
Revised January 2018
협조는 성공적인 설문조사를 위해 중요합니다. 귀하의 도움에 감사드립니다. 미국
지역사회 설문조사에 관한 보다 자세한 정보는 웹사이트 http://www.census.gov/acs
에서 확인하십시오.
감사합니다.
프로그램 감독관
전화 통화 가능한 시간:
전화 통화 가능한 번호:
선호하는 언어:
ACS-613N(L)(RUSSIAN)
Revised January 2018
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
Уважаемый(-ая) <>:
Ваш адрес выбран для участия в Анкетировании населения США по месту жительства
(ACS). Представитель Бюро переписи США, <>, недавно пытался связаться с
вами для прохождения анкетирования. Это анкетирование проводится Бюро переписи и
позволяет получить критически важную и актуальную информацию, которая
используется для удовлетворения потребностей сообществ, проживающих на всей
территории Соединенных Штатов. Вся информация собирается согласно пункту 13,
разделов 141, 193 и 221 Кодекса Соединенных Штатов.
В Анкетировании населения США по месту жительства содержатся вопросы о
характеристиках домохозяйств, включая такие темы, как образование, занятость и жилье.
Эти вопросы позволяют осуществить сбор данных, необходимых для управления и
оценки функционирования государственных программ. Анкетирование населения США
по месту жительства (ACS) будет предоставлять сообществам ежегодно обновляемую
подробную информацию, ранее доступную только каждые 10 лет, когда Бюро переписи
проводило перепись населения.
В силу важности этого анкетирования мы будем признательны, если вы сообщите нам,
как связаться с вами, заполнив информационную форму в нижней части этого письма и
отправив ее нам в конверте с предварительно оплаченным почтовым сбором. Вы также
можете позвонить <> по номеру <> или <>,
руководителю программы, по номеру <>. Мы будем рады организовать
интервью в удобное для вас время и провести его в кратчайшие сроки.
В соответствии с законом Бюро переписи США обязано сохранять конфиденциальность
вашей информации. Нам не разрешается публиковать ваши ответы таким образом,
чтобы можно было идентифицировать конкретное домохозяйство. В соответствии с
Федеральным законом об усилении кибербезопасности от 2015 года ваши данные
защищены от рисков нарушения кибербезопасности посредством скрининга систем,
которые передают ваши данные. По закону Бюро переписи может использовать ваши
ответы только для получения статистических данных. Ваше участие и сотрудничество
очень важны для успешного проведения анкетирования. Благодарю за помощь! Для
получения дополнительной информации об Анкетировании населения США по месту
жительства посетите наш веб-сайт по адресу http://www.census.gov/acs.
С уважением,
руководитель программы
ACS-613N(L)(RUSSIAN)
Revised January 2018
Время, когда со мной обычно можно связаться:
Номер телефона, по которому со мной обычно можно связаться:
Предпочтительный язык:
ACS-613N(L)(VIETNAMESE)
Revised January 2018
APPROVED NO ONE HOME LETTER
<>
<>
<>
<>
Kính gửi <>:
Địa chỉ của quý vị đã được chọn để tham gia vào cuộc Khảo Sát Cộng Đồng tại Mỹ
(American Community Survey, ACS). Gần đây, một đại diện của Cục Thống Kê Dân Số
Hoa Kỳ, <>, đã cố gắng liên hệ với quý vị để hoàn tất bài khảo sát. Cuộc
khảo sát này do Cục Thống Kê Dân Số tiến hành để cung cấp các thông tin quan trọng,
cập nhật được sử dụng nhằm đáp ứng nhu cầu của các cộng đồng trên toàn Hoa Kỳ.
Mọi thông tin được thu thập theo thẩm quyền của Mục 13, Phần 141, 193 và 221 của
Đạo Luật Hoa Kỳ.
Cuộc Khảo Sát Cộng Đồng tại Mỹ gồm các câu hỏi về đặc điểm hộ gia đình của quý vị
bao gồm các chủ đề như giáo dục, việc làm và nhà ở. Những câu hỏi này được yêu
cầu để thu thập dữ liệu cần thiết nhằm quản lý hoặc đánh giá chương trình của chính
phủ. ACS sẽ cung cấp cho cộng đồng thông tin cập nhật, chi tiết hàng năm mà trước
đó chỉ có khi Cục Thống Kê Dân Số tiến hành điều tra dân số 10 năm một lần.
Do tầm quan trọng của cuộc khảo sát này, chúng tôi sẽ đánh giá cao nếu quý vị cho
chúng tôi biết cách liên hệ với quý vị bằng cách điền thông tin vào phần cuối thư này và
gửi lại bằng phong bì đã trả bưu phí. Quý vị cũng có thể gọi cho <> theo số
<> hoặc <>, Giám Sát Viên Chương Trình, theo số
<>. Chúng tôi sẽ sẵn lòng bố trí phỏng vấn theo lịch của quý vị và
tiến hành phỏng vấn nhanh nhất có thể.
Luật pháp yêu cầu Cục Thống Kê Dân Số Hoa Kỳ giữ bảo mật thông tin của quý vị.
Chúng tôi không được phép công bố công khai phần trả lời của quý vị theo cách thức
có thể xác định hộ gia đình này. Theo Đạo Luật Củng Cố An Ninh Mạng Liên Bang
2015, dữ liệu của quý vị được bảo vệ khỏi các rủi ro an ninh mạng thông qua sàng lọc
các hệ thống truyền tải dữ liệu của quý vị. Theo luật, Cục Thống Kê Dân Số chỉ có thể
sử dụng phần trả lời của quý vị để lập số liệu thống kê. Sự tham gia và hợp tác của
quý vị rất quan trọng để khảo sát này thành công. Cảm ơn sự giúp đỡ của quý vị. Để
biết thêm thông tin về Khảo Sát Cộng Đồng tại Mỹ, xin hãy truy cập trang web của
chúng tôi tại địa chỉ http://www.census.gov/acs.
Trân trọng,
Giám Sát Viên Chương Trình
ACS-613N(L)(VIETNAMESE)
Revised January 2018
Thời gian có thể liên hệ với tôi:
Số điện thoại có thể liên hệ với tôi:
Ưu Tiên Ngôn Ngữ:
ACS-613N(L)(ENGLISH) No Mail Back
Revised June 2017
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
Dear <>:
Your address has been selected for participation in the American Community Survey (ACS). A
U.S. Census Bureau representative, <>, recently tried to contact you to complete
the survey. This survey is conducted by the Census Bureau to produce critical, up-to-date
information that is used to meet the needs of communities across the United States. All
information is collected under the authority of Title 13, Sections 141, 193, and 221, of the
United States Code.
The American Community Survey contains questions about your household characteristics
including such topics as education, employment, and housing. These questions are required to
collect data needed to manage or evaluate government programs. The ACS will provide
communities annually updated, detailed information previously available only when the Census
Bureau conducted a census every 10 years.
Because of the importance of the survey, we would appreciate if you would call <>
at <> or <>, Program Supervisor, on<>.
We will be happy to arrange an interview at your convenience and conduct the interview as
quickly as possible.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from
cybersecurity risks through screening of the systems that transmit your data. By law, the
Census Bureau can only use your responses to produce statistics. Your participation and
cooperation are important to the success of the survey. Thank you for your help. For more
information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Sincerely,
Program Supervisor
ACS-613N(L)(CHINESE) No Mail Back
Revised January 2018
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
尊敬的 <>：
您的地址已被选中参加美国社区调查 (ACS)。美国人口普查局代表 <> 最近试
图联系您以完成调查。本调查由人口普查局执行，以生成重要、最新信息，用于满足美
国各个社区的需求。人口普查局在美国法典第 13 章第 141、193 和 221 节的授权下收
集所有信息。
美国社区调查包含关于家庭特征的问题，包括教育、就业和住房等主题。收集管理或评
估政府计划所需数据必须提出这些问题。ACS 将每年向社区提供最新、详细的信息，以
前只有在人口普查局每隔 10 年进行人口普查时才会提供这些信息。
因为调查的重要性，如果您能够拨打电话 <> 联系 <>，或拨打
<> 联系项目主管 <>，我们将不胜感激。我们将很乐意安
排在您方便的时间尽快进行面谈。
法律要求美国人口普查局将您的信息保密。我们不允许以可能识别此家庭的方式公开发
布您的回复。根据 2015 年联邦网络安全增强法案，我们通过筛查传输您的数据的系统，
消除您的数据的网络安全风险。根据法律，人口普查局只能使用您的回复生成统计数据。
您的参与和合作对调查取得成功很重要。感谢您的帮助。有关美国社区调查的详细信息，
请访问我们的网站 http://www.census.gov/acs。
此致，
项目主管
ACS-613N(L)(KOREAN) No Mail Back
Revised January 2018
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
<>님께:
귀하의 주소는 미국 지역사회 설문조사 (ACS)에 참여하기 위하여 선택되었습니다. 미국
통계청 직원인 <>이(가) 최근에 설문조사 작성을 위하여 귀하께 연락을
시도하였습니다. 본 설문조사는 매우 중요한 최신 정보를 얻기 위해 통계청에 의해서
수행되며, 이 정보는 미국 전역에 걸친 지역사회의 요구에 부합하기 위하여 사용됩니다.
모든 정보는 미국 연방 법령 제13장 141, 193 및 221 조항에 의거하여 수집됩니다.
미국 지역사회 설문조사는 교육, 고용 및 주택과 같은 주제를 포함하여 가정의 특성과
관련된 질문을 포함하고 있습니다. 이러한 질문사항은 정부 프로그램을 관리하거나
평가하기 위해 필요한 정보를 수집하기 위해 요구됩니다. ACS는 통계청이 예전에는
10년 마다 인구조사를 수행했을 경우에만 이용가능한 상세 정보를 매년 갱신해서
지역사회에 제공합니다.
설문조사의 중요성으로 인하여 <>번으로 <>에게
전화주시거나 프로그램 감독관인 <>에게
<>번으로 연락주시면 감사하겠습니다. 귀하의 편의에 맞추어
인터뷰를 예약하고 가능한 빠른 시간내에 인터뷰를 수행하도록 하겠습니다.
미국 통계청은 법률에 따라 귀하의 정보를 기밀로 유지합니다. 저희가 참여 가정을
식별할 수 있는 방법으로 귀하의 답변을 공개적으로 발표하는 것은 허용되지 않습니다.
2015년 연방 사이버보안 개선 법안에 따라서 데이터를 전송하는 시스템의 검사를
통하여 귀하의 데이터를 사이버 보안 위험으로부터 보호합니다. 법률에 의거하여
통계청에서는 귀하의 응답을 통계 목적으로만 사용할 수 있습니다. 귀하의 참여와
협조는 성공적인 설문조사를 위해 중요합니다. 귀하의 도움에 감사드립니다. 미국
ACS-613N(L)(KOREAN) No Mail Back
Revised January 2018
지역사회 설문조사에 관한 보다 자세한 정보는 웹사이트 http://www.census.gov/acs
에서 확인하십시오.
감사합니다.
프로그램 감독관
ACS-613N(L)(RUSSIAN) No Mail Back
Revised January 2018
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
Уважаемый(-ая) <>:
Ваш адрес выбран для участия в Анкетировании населения США по месту жительства
(ACS). Представитель Бюро переписи США, <>, недавно пытался связаться с
вами для прохождения анкетирования. Это анкетирование проводится Бюро переписи и
позволяет получить критически важную и актуальную информацию, которая
используется для удовлетворения потребностей сообществ, проживающих на всей
территории Соединенных Штатов. Вся информация собирается согласно пункту 13,
разделов 141, 193 и 221 Кодекса Соединенных Штатов.
В Анкетировании населения США по месту жительства содержатся вопросы о
характеристиках домохозяйств, включая такие темы, как образование, занятость и жилье.
Эти вопросы позволяют осуществить сбор данных, необходимых для управления и
оценки функционирования государственных программ. Анкетирование населения США
по месту жительства (ACS) будет предоставлять сообществам ежегодно обновляемую
подробную информацию, ранее доступную только каждые 10 лет, когда Бюро переписи
проводило перепись населения.
В силу важности этого анкетирования мы будем признательны, если вы позвоните
<> по номеру << FRPHONE >> или <>, руководителю
программы, по номеру <>. Мы будем рады организовать интервью в
удобное для вас время и провести его в кратчайшие сроки.
В соответствии с законом Бюро переписи США обязано сохранять конфиденциальность
вашей информации. Нам не разрешается публиковать ваши ответы таким образом,
чтобы можно было идентифицировать конкретное домохозяйство. В соответствии с
Федеральным законом об усилении кибербезопасности от 2015 года ваши данные
защищены от рисков нарушения кибербезопасности посредством скрининга систем,
которые передают ваши данные. По закону Бюро переписи может использовать ваши
ответы только для получения статистических данных. Ваше участие и сотрудничество
очень важны для успешного проведения анкетирования. Благодарю за помощь! Для
получения дополнительной информации об Анкетировании населения США по месту
жительства посетите наш веб-сайт по адресу http://www.census.gov/acs.
С уважением,
руководитель программы
ACS-613N(L)(RUSSIAN) No Mail Back
Revised January 2018
ACS-613N(L)(SPANISH) No Mail Back
Revised September 2017
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
Estimado(a) <>:
Su dirección fue seleccionada para participar en la Encuesta sobre la Comunidad Estadounidense
(ACS). Un representante de la Oficina del Censo de los EE. UU., <>, intentó
comunicarse con usted recientemente para completar la encuesta. La Oficina del Censo lleva a
cabo esta encuesta a fin de generar información fundamental y actualizada que se usa para
satisfacer las necesidades de las comunidades en todos los Estados Unidos. Toda la información
se recopila en conformidad con la autoridad de las Secciones 141, 193 y 221 del Título 13 del
Código de los Estados Unidos.
La Encuesta sobre la Comunidad Estadounidense contiene preguntas sobre las características del
hogar, incluidos temas como la educación, el empleo y la vivienda. Estas preguntas son
necesarias para recopilar datos precisos para gestionar o evaluar programas del gobierno. La
ACS les proporcionará a las comunidades información anual actualizada y detallada que
previamente solo estaba disponible cuando la Oficina del Censo llevaba a cabo el censo cada 10
años.
Debido a la importancia de la encuesta, le agradeceríamos que llamara a <> al
<> o a <>, el supervisor del programa, al
<>. Será un placer concertar una entrevista a su conveniencia y realizarla tan
rápido como sea posible.
La Oficina del Censo de los EE. UU. está obligada por ley a mantener confidencial su
información. No se nos permite divulgar sus respuestas de manera que su hogar pudiera ser
identificado. En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética
Federal del 2015, sus datos están protegidos contra los riesgos de seguridad cibernética mediante
los controles aplicados a los sistemas que los transmiten. Por ley, la Oficina del Censo puede
usar sus respuestas solamente para producir estadísticas. Su participación y cooperación son
importantes para el éxito de la encuesta. Le agradecemos por su ayuda. Para obtener más
información sobre la Encuesta sobre la Comunidad Estadounidense, visite nuestro sitio web en
http://www.census.gov/acs.
Atentamente,
Supervisor del programa
ACS-613N(L)(VIETNAMESE) No Mail Back
Revised January 2018
APPROVED NO ONE HOME LETTER (NO MAIL BACK)
<>
<>
<>
<>
Kính gửi <>:
Địa chỉ của quý vị đã được chọn để tham gia vào cuộc Khảo Sát Cộng Đồng tại Mỹ
(American Community Survey, ACS). Gần đây, một đại diện của Cục Thống Kê Dân Số
Hoa Kỳ, <>, đã cố gắng liên hệ với quý vị để hoàn tất bài khảo sát. Cuộc
khảo sát này do Cục Thống Kê Dân Số tiến hành để cung cấp các thông tin quan trọng,
cập nhật được sử dụng nhằm đáp ứng nhu cầu của các cộng đồng trên toàn Hoa Kỳ.
Mọi thông tin được thu thập theo thẩm quyền của Mục 13, Phần 141, 193 và 221 của
Đạo Luật Hoa Kỳ.
Cuộc Khảo Sát Cộng Đồng tại Mỹ gồm các câu hỏi về đặc điểm hộ gia đình của quý vị
bao gồm các chủ đề như giáo dục, việc làm và nhà ở. Những câu hỏi này được yêu
cầu để thu thập dữ liệu cần thiết nhằm quản lý hoặc đánh giá chương trình của chính
phủ. ACS sẽ cung cấp cho cộng đồng thông tin cập nhật, chi tiết hàng năm mà trước
đó chỉ có khi Cục Thống Kê Dân Số tiến hành điều tra dân số 10 năm một lần.
Vì tầm quan trọng của cuộc khảo sát này, chúng tôi sẽ đánh giá cao nêu quý vị gọi cho
<> theo số <> hoặc <>, Giám Sát Viên
Chương Trình, theo số <>. Chúng tôi sẽ sẵn lòng bố trí phỏng vấn
theo lịch của quý vị và tiến hành phỏng vấn nhanh nhất có thể.
Luật pháp yêu cầu Cục Thống Kê Dân Số Hoa Kỳ giữ bảo mật thông tin của quý vị.
Chúng tôi không được phép công bố công khai phần trả lời của quý vị theo cách thức
có thể xác định hộ gia đình này. Theo Đạo Luật Củng Cố An Ninh Mạng Liên Bang
2015, dữ liệu của quý vị được bảo vệ khỏi các rủi ro an ninh mạng thông qua sàng lọc
các hệ thống truyền tải dữ liệu của quý vị. Theo luật, Cục Thống Kê Dân Số chỉ có thể
sử dụng phần trả lời của quý vị để lập số liệu thống kê. Sự tham gia và hợp tác của
quý vị rất quan trọng để khảo sát này thành công. Cảm ơn sự giúp đỡ của quý vị. Để
biết thêm thông tin về Khảo Sát Cộng Đồng tại Mỹ, xin hãy truy cập trang web của
chúng tôi tại địa chỉ http://www.census.gov/acs.
Trân trọng,
Giám Sát Viên Chương Trình
Final Attempt
Revised June 2017
APPROVED FINAL ATTEMPT LETTER
<>
<>
<>
<>
Dear <>:
Your address has been selected for participation in the American Community Survey. A U.S.
Census Bureau representative, <>, recently tried to contact you to complete the
survey. This survey is conducted by the Census Bureau to produce critical, up-to-date
information that is used to meet the needs of communities across the United States. All
information is collected under the authority of Title 13, Sections 141, 193, and 221, of the United
States Code.
The American Community Survey contains questions about household characteristics including
such topics as education, employment, and housing. It produces critical, up-to-date information
that is used to meet the needs of communities across the United States. For example, results
from this survey may be used to decide where new schools, hospitals, and fire stations are
needed. Survey data are used by federal, state, and local governments to make decisions and to
develop programs that will provide health care, education, and transportation services that affect
you and your community. This survey information also helps communities plan for emergency
situations that might affect you and your neighbors.
The U.S. Census Bureau is required by law to keep your information confidential. We are not
permitted to publicly release your responses in a way that could identify this household. Per the
Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity
risks through screening of the systems that transmit your data. By law, the Census Bureau can
only use your responses to produce statistics.
We are in the final days of collecting data on the American Community Survey for your address,
and we have not been able to include data from your household. Because of the importance of
the survey, we would appreciate if you would contact us to conduct the interview by telephone or
in person. You may call the Field Representative who has previously attempted to contact you,
or call us at our Regional Office at <>. We would like to complete your
interview within the next five (5) days.
You can also complete the survey online by going to https://respond.census.gov/acs and logging
on using the following User ID number: <>. Your participation and
cooperation are important to the success of the survey. Your response does make a difference!
If you have further concerns or questions, please call <> at <>, or the
Program Supervisor, <>. We will be pleased to help you. For more
information about the American Community Survey, visit our website at
http://www.census.gov/acs.
Final Attempt
Revised June 2017
Sincerely,
Program Supervisor
Attachment VI: Fifth Mailing Letter (ACS-23)
DC
U.S. Census Bureau
Washington, DC 20233
Office of the Director
A message from the Director, U.S. Census Bureau ...
The U.S. Census Bureau has sent you several requests to complete the American
Community Survey. If you have not already done so, now is the time to respond.
Due: November 22, 2019
Respond now at https://respond.census.gov/acs
Log in using this user ID:
OR complete and mail back your paper questionnaire.
Your response is required by law.
Because your response is critically important to your local community and to your country, a
Census Bureau interviewer may come to your home to complete the survey in person.
Respond by November 22, 2019 to be removed from our schedule for a visit.
If you would like to complete the survey by telephone or need assistance, please call our
toll-free number (1–800–354–7271).
Thank you.
Sincerely,
Steven D. Dillingham
census.gov
DC
PRESORTED
FIRST-CLASS MAIL
POSTAGE & FEES PAID
U.S. Census Bureau
Permit No. G-58
U.S. Census Bureau
National Processing Center
1201 E 10th Street
Jeffersonville IN 47132
OFFICIAL BUSINESS
Penalty for Private Use $300
FINAL NOTICE
RESPONSE DUE:
NOVEMBER 22, 2019
ACS-23(LX)(DDT)(BOD) (07-10-2019)
| File Type | application/pdf |
| Author | Marcella S Jones-Puthoff (CENSUS/ACSO FED) |
| File Modified | 2020-03-20 |
| File Created | 2020-02-27 |