Form 1 Question wording by treatment

13212022

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

6

What is Person 1’s race?
Mark (X) one or more boxes AND print origins.
White – Print, for example, German, Irish, English,
Italian, Lebanese, Egyptian, etc. C

How is this person related to Person 1?
X

3

MI

Person 1
Black or African Am. – Print, for example,
African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc. C

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.
Print numbers in boxes.
Age (in years)

Month

Day

Year of birth
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

4

What sex was Person 1 assigned at birth?
Mark (X) ONE box.
Male

5

Female

What is Person 1's current gender?

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

Skip this question if this person is less than 15 years old.
Mark (X) ONE box.
Male
Female
Transgender

Some other race – Print race or origin. C

Nonbinary
Person 1 uses a different term. Specify

§.657¤

2

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

13212030

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

What is Person 2’s name?

5

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.
Spouse
Unmarried partner

6

Biological child
Adopted child

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

Stepchild
Sibling
Parent

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

Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative

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

Roommate or housemate
Foster child
Other nonrelative

3

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)

4

Day

Year of birth

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

What sex was Person 2 assigned at birth?
Mark (X) ONE box.
Male

5

Month

Chinese

Female

What is Person 2's current gender?
Skip this question if this person is less than 15 years old.
Mark (X) ONE box.

Some other race – Print race or origin. C

Male
Female
Transgender
Nonbinary
This person uses a different term. Specify

§.65?¤

3

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

(Pages for Persons 3-5 are identical to Person 2)

13212071

➜

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)

First Name

Sex at birth

Age (in years)

Male

MI

Female

Person 7
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

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

§.65h¤

Age (in years)

7

13212121

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
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

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)

§.666¤

12

13212139

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

Name of U.S. county or municipio in Puerto Rico

(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. state or
Puerto Rico

ZIP Code

14 a. Does this person speak a language other
than English at home?
Yes

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

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

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.66H¤

13

Yes

No

13212147

Person 1 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

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.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

No difficulty
Some difficulty

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?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 2 on page 19.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

21 What is this person’s marital status?
Now married

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.66P¤

14

J on the next page

13212154

Person 1 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

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.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)
Yes (such as 0%, 10%, 20%, ... , 100%)

May 1975 to July 1990

No ➔ SKIP to question 30a

J

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

Answer question 25 if this person is female and
15 – 50 years old. Otherwise, SKIP to question 26a.

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

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own
grandchildren under the age of 18 living in
this house or apartment?
Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

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?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.66W¤

15

13212162

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 40.

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 40

Ferryboat

Other method

§.66_¤

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

13212170

Person 1 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 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 for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

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)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.66g¤

17

13212196

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
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas

11 What is the highest grade of school or degree this
person has COMPLETED? Mark (X) ONE box.
If currently enrolled, select the previous grade or
highest degree received.

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

LESS THAN GRADE 1

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

Less than grade 1
GRADE 1 THROUGH GRADE 12
Grade 1 through 11 – Specify
grade 1 – 11

No, not a U.S. citizen

9

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.

12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE

Year

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)

§.66£¤

19

13212204

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

Name of U.S. county or municipio in Puerto Rico

(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. state or
Puerto Rico

ZIP Code

14 a. Does this person speak a language other
than English at home?
Yes

16 Is this person CURRENTLY covered by any of the
following types of health insurance or health
coverage plans?
Do NOT include plans that cover only one type of
service, such as dental, drug, or vision plans.
Mark "Yes" or "No" for EACH type of coverage in
items a – h.

No ➔ SKIP to question 15a

b. What is this language?

a. Insurance through a current or former
employer, union, or professional
association (of this person or another
family member)

For example: Korean, Italian, Spanish, Vietnamese
c. How well does this person speak English?
Very well

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

Well

c. Medicaid, Children’s Health Insurance
Program (CHIP), or any kind of
government-assistance plan for those
with low incomes or a disability

Not well
Not at all

d. Insurance purchased directly from an
insurance company, a broker, or a
State or Federal Marketplace, such as
Healthcare.gov
e. Veteran’s health care (enrolled for VA)
f. TRICARE or other military health care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify C

§.67%¤

20

Yes

No

13212212

Person 2 (continued)

G

b. Does this person have difficulty remembering
or concentrating?

Answer question 17a if this person is covered by
health insurance. Otherwise, SKIP to question 18a.

No difficulty
Some difficulty

17 a. Is there a premium for this plan? A premium

A lot of difficulty

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.

Cannot do at all

c. Does this person have difficulty with self-care,
such as washing all over or dressing?

Yes

No difficulty

No ➔ SKIP to question 18a

Some difficulty

b. Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?

A lot of difficulty
Cannot do at all

Yes

d. Using his or her usual language, does this
person have difficulty communicating, for
example understanding or being understood?

No

18 a. Does this person have difficulty seeing, even

No difficulty

if wearing glasses?
No difficulty

Some difficulty

Some difficulty

A lot of difficulty

A lot of difficulty

Cannot do at all

Cannot do at all

b. Does this person have difficulty hearing, even
if using a hearing aid?

I

Answer question 20 if this person is 15 years old
or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

No difficulty
Some difficulty

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?

A lot of difficulty
Cannot do at all

No difficulty

H

Some difficulty

Answer questions 19a – d if this person is 5 years
old or over. Otherwise, SKIP to the questions for
Person 3 on page 26.

A lot of difficulty
Cannot do at all

19 a. Does this person have difficulty walking or
climbing steps?

21 What is this person’s marital status?
Now married

No difficulty

Widowed
Some difficulty
Divorced
A lot of difficulty
Separated
Cannot do at all
Never married ➔ SKIP to

§.67-¤

21

J on the next page

13212220

Person 2 (continued)
22 In the PAST 12 MONTHS did this person get –
Yes

27 Has this person ever served on active duty in the
U.S. Armed Forces, Reserves, or National Guard?
Mark (X) ONE box.

No

a. Married?

Never served in the military ➔ SKIP to question 30a

b. Widowed?

Only on active duty for training in the Reserves
or National Guard ➔ SKIP to question 29a

c. Divorced?

Now on active duty

23 How many times has this person been married?

On active duty in the past, but not now

Once
Two times

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.

Three or more times

September 2001 or later

24 In what year did this person last get married?

August 1990 to August 2001 (including
Persian Gulf War)

Year

May 1975 to July 1990
Vietnam era (August 1964 to April 1975)

J

February 1955 to July 1964
Korean War (July 1950 to January 1955)
January 1947 to June 1950

25 In the PAST 12 MONTHS, has this person given

World War II (December 1941 to December 1946)

birth to any children?

November 1941 or earlier

Yes
No

29 a. Does this person have a VA service-connected
disability rating?

26 a. Does this person have any of his/her own

Yes (such as 0%, 10%, 20%, ... , 100%)

grandchildren under the age of 18 living in
this house or apartment?

No ➔ SKIP to question 30a

Yes

b. What is this person’s service-connected
disability rating?

No ➔ SKIP to question 27

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?

0 percent
10 or 20 percent
30 or 40 percent

Yes

50 or 60 percent

No ➔ SKIP to question 27

70 percent or higher

c. How long has this grandparent been responsible
for these grandchildren? If the grandparent is
financially responsible for more than one grandchild,
answer the question for the grandchild for whom
the grandparent has been responsible for the
longest period of time.
Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

§.675¤

22

13212238

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 40.

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 40

Ferryboat

Other method

§.67G¤

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

13212246

Person 2 (continued)
37 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?

M

Answer questions 43a – f if this person worked in
the past 5 years. Otherwise, SKIP to question 44.

Yes
No ➔ SKIP to question 39

43 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 for pay, even
for a few days?

PRIVATE SECTOR EMPLOYEE

Within the past 12 months

For-profit company or organization

1 to 5 years ago

Non-profit organization (including
tax-exempt and charitable organizations)

Over 5 years ago or never worked ➔ SKIP to
question 44

GOVERNMENT EMPLOYEE

40 In 2021, did this person work for pay, even for
a few days?

Local government (for example: city or
county school district)
State government (including state
colleges/universities)

Yes
No ➔ SKIP to question 43

➜

Active duty U.S. Armed Forces or
Commissioned Corps

NOTE: For question 41a and b, include as WORK:
✓ all jobs for pay
✓ paid vacation
✓ paid sick leave
✓ military service

Federal government civilian employee
SELF-EMPLOYED OR OTHER

Owner of non-incorporated business,
professional practice, or farm

41 a. In 2021 (52 weeks), did this person work

Owner of incorporated business,
professional practice, or farm

EVERY week? Remember to include paid vacation
and paid sick leave as work.

Worked without pay in a for-profit family
business or farm for 15 hours or more per week

Yes ➔ SKIP to question 42
No

b. What was the name of this person’s employer,
business, agency, or branch of the
Armed Forces?

b. In 2021 (52 weeks), how many WEEKS did this
person work for at least one day? Include weeks
when this person only worked for a few hours.
Weeks

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)

42 In 2021, for the weeks worked, how many HOURS
did this person usually work each WEEK?
Include all jobs for pay and military service.
Usual hours worked each WEEK

d. Was this mainly – Mark (X) ONE box.
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

§.67O¤

24

(Pages for Persons 3-5 are identical to Person 2)