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OCR for page 101
Appendix B
2011 American Community Survey:
Housing Unit Questionnaire
101
OCR for page 102
102 SMALL POPULATIONS, LARGE EFFECTS
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191010
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
DC
U.S. CENSUS BUREAU
American Community Survey
THE
This booklet shows the
content of the
American Community Survey
questionnaire.
Please complete this form and return
Start Here
it as soon as possible after receiving
it in the mail. Please print today’s date.
➜
Month Day Year
This form asks for information about
➜ Please print the name and telephone number of the person who is
the people who are living or staying at filling out this form. We may contact you if there is a question.
Last Name
the address on the mailing label and
about the house, apartment, or mobile
First Name MI
home located at the address on the
mailing label.
Area Code + Number
—
If you need help or have questions
about completing this form, please call
➜
1-800-354-7271. The telephone call is free. How many people are living or staying at this address?
● INCLUDE everyone who is living or staying here for more than 2 months.
Telephone Device for the Deaf (TDD): ● INCLUDE yourself if you are living here for more than 2 months.
Call 1–800–582–8330. The telephone call is free. ● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
¿NECESITA AYUDA? Si usted habla español y ● DO NOT INCLUDE anyone who is living somewhere else for more than
necesita ayuda para completar su cuestionario, 2 months, such as a college student living away or someone in the
llame sin cargo alguno al 1-877-833-5625. Armed Forces on deployment.
Usted también puede pedir un cuestionario en Number of people
español o completar su entrevista por teléfono
con un entrevistador que habla español.
For more information about the American
➜ Fill out pages 2, 3, and 4 for everyone, including yourself, who is
Community Survey, visit our web site at: living or staying at this address for more than 2 months. Then
http://www.census.gov/acs/www/ complete the rest of the form.
ACS-1(INFO)(2011)KFI OMB No. 0607-0810
USCENSUSBUREAU FORM
(06-14-2010)
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103
APPENDIX B
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191028
Person 1 Person 2
1 What is Person 2’s name?
Last Name (Please print) First Name MI
(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.)
2 How is this person related to Person 1? Mark (X) ONE box.
Husband or wife Son-in-law or daughter-in-law
Biological son or daughter Other relative
1 What is Person 1’s name? Adopted son or daughter Roomer or boarder
Last Name (Please print) First Name MI Stepson or stepdaughter Housemate or roommate
Brother or sister Unmarried partner
Father or mother Foster child
2 How is this person related to Person 1? Grandchild Other nonrelative
X Person 1 Parent-in-law
3 3 What is Person 2’s sex? Mark (X) ONE box.
What is Person 1’s sex? Mark (X) ONE box.
Male Female Male Female
4 4 What is Person 2’s age and what is Person 2’s date of birth?
What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old. Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes. Print numbers in boxes.
Age (in years) Month Day Year of birth Age (in years) Month Day Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races. Question 6 about race. For this survey, Hispanic origins are not races.
5 5 Is Person 2 of Hispanic, Latino, or Spanish origin?
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican Yes, Puerto Rican
Yes, Cuban Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. and so on.
6 6 What is Person 2’s race? Mark (X) one or more boxes.
What is Person 1’s race? Mark (X) one or more boxes.
White White
Black, African Am., or Negro Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian Japanese Asian Indian Japanese
Native Hawaiian Native Hawaiian
Chinese Korean Chinese Korean
Guamanian or Chamorro Guamanian or Chamorro
Filipino Vietnamese Filipino Vietnamese
Samoan Samoan
Other Asian – Print race, Other Pacific Islander – Other Asian – Print race, Other Pacific Islander –
for example, Hmong, Print race, for example, for example, Hmong, Print race, for example,
Laotian, Thai, Pakistani, Fijian, Tongan, and Laotian, Thai, Pakistani, Fijian, Tongan, and
Cambodian, and so on. so on. Cambodian, and so on. so on.
Some other race – Print race. Some other race – Print race.
§.4+=¤
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104 SMALL POPULATIONS, LARGE EFFECTS
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191036
Person 3 Person 4
1 1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print) First Name Last Name (Please print) First Name
MI MI
2 2 How is this person related to Person 1? Mark (X) ONE box.
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife Son-in-law or daughter-in-law Husband or wife Son-in-law or daughter-in-law
Biological son or daughter Other relative Biological son or daughter Other relative
Adopted son or daughter Roomer or boarder Adopted son or daughter Roomer or boarder
Stepson or stepdaughter Housemate or roommate Stepson or stepdaughter Housemate or roommate
Brother or sister Unmarried partner Brother or sister Unmarried partner
Father or mother Foster child Father or mother Foster child
Grandchild Other nonrelative Grandchild Other nonrelative
Parent-in-law Parent-in-law
3 3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Male Female Male Female
4 4 What is Person 4’s age and what is Person 4’s date of birth?
What is Person 3’s age and what is Person 3’s date of birth?
Please report babies as age 0 when the child is less than 1 year old. Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes. Print numbers in boxes.
Age (in years) Month Day Year of birth Age (in years) Month Day Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races. Question 6 about race. For this survey, Hispanic origins are not races.
5 5 Is Person 4 of Hispanic, Latino, or Spanish origin?
Is Person 3 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican Yes, Puerto Rican
Yes, Cuban Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. and so on.
6 6 What is Person 4’s race? Mark (X) one or more boxes.
What is Person 3’s race? Mark (X) one or more boxes.
White White
Black, African Am., or Negro Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. American Indian or Alaska Native — Print name of enrolled or principal tribe.
Asian Indian Japanese Asian Indian Japanese
Native Hawaiian Native Hawaiian
Chinese Korean Chinese Korean
Guamanian or Chamorro Guamanian or Chamorro
Filipino Vietnamese Filipino Vietnamese
Samoan Samoan
Other Asian – Print race, Other Pacific Islander – Other Asian – Print race, Other Pacific Islander –
for example, Hmong, Print race, for example, for example, Hmong, Print race, for example,
Laotian, Thai, Pakistani, Fijian, Tongan, and Laotian, Thai, Pakistani, Fijian, Tongan, and
Cambodian, and so on. so on. Cambodian, and so on. so on.
Some other race – Print race. Some other race – Print race.
§.4+E¤ 3
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105
APPENDIX B
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191044
Person 5 ➜ If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
1 What is Person 5’s name? We may call you for more information about them.
Last Name (Please print) First Name MI
Person 6
Last Name (Please print) First Name MI
2 How is this person related to Person 1? Mark (X) ONE box.
Husband or wife Son-in-law or daughter-in-law
Biological son or daughter Other relative
Sex Age (in years)
Male Female
Adopted son or daughter Roomer or boarder
Stepson or stepdaughter Housemate or roommate
Person 7
Brother or sister Unmarried partner Last Name (Please print) First Name MI
Father or mother Foster child
Grandchild Other nonrelative
Parent-in-law
3 What is Person 5’s sex? Mark (X) ONE box. Sex Male Female Age (in years)
Male Female
Person 8
4 What is Person 5’s age and what is Person 5’s date of birth? Last Name (Please print) First Name MI
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years) Month Day Year of birth
Sex Male Female Age (in years)
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
Person 9
5 Is Person 5 of Hispanic, Latino, or Spanish origin? Last Name (Please print) First Name MI
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban Sex Male Female Age (in years)
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, Person 10
and so on.
Last Name (Please print) First Name MI
6 What is Person 5’s race? Mark (X) one or more boxes.
White
Sex Male Female Age (in years)
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe.
Person 11
Last Name (Please print) First Name MI
Asian Indian Japanese Native Hawaiian
Chinese Korean Guamanian or Chamorro
Filipino Vietnamese Samoan Sex Male Female Age (in years)
Other Asian – Print race, Other Pacific Islander –
for example, Hmong, Print race, for example, Person 12
Laotian, Thai, Pakistani, Fijian, Tongan, and
Cambodian, and so on. so on. Last Name (Please print) First Name MI
Some other race – Print race.
Sex Male Female Age (in years)
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106 SMALL POPULATIONS, LARGE EFFECTS
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191051
Housing
➜ 8 Does this house, apartment, or mobile
Please answer the following
A Answer questions 4 – 6 if this is a HOUSE home have –
questions about the house,
OR A MOBILE HOME; otherwise, SKIP to Yes No
apartment, or mobile home at the
question 7a.
address on the mailing label. a. hot and cold running water?
b. a flush toilet?
1 Which best describes this building? 4 How many acres is this house or
c. a bathtub or shower?
Include all apartments, flats, etc., even if mobile home on?
vacant.
d. a sink with a faucet?
Less than 1 acre ➔ SKIP to question 6
A mobile home
1 to 9.9 acres e. a stove or range?
A one-family house detached from any
10 or more acres
other house f. a refrigerator?
A one-family house attached to one or
g. telephone service from
more houses which you can both make
5 IN THE PAST 12 MONTHS, what and receive calls? Include
A building with 2 apartments
cell phones.
were the actual sales of all agricultural
A building with 3 or 4 apartments products from this property?
A building with 5 to 9 apartments
None 9 How many automobiles, vans, and trucks
A building with 10 to 19 apartments
of one-ton capacity or less are kept at
$1 to $999
A building with 20 to 49 apartments home for use by members of this
$1,000 to $2,499 household?
A building with 50 or more apartments
$2,500 to $4,999
Boat, RV, van, etc. None
$5,000 to $9,999
1
$10,000 or more
2
2 About when was this building first built? 3
6 Is there a business (such as a store or 4
2000 or later – Specify year
barber shop) or a medical office on
5
this property?
6 or more
Yes
1990 to 1999 No
10 Which FUEL is used MOST for heating this
1980 to 1989
house, apartment, or mobile home?
1970 to 1979 7 a. How many separate rooms are in this
house, apartment, or mobile home?
1960 to 1969 Gas: from underground pipes serving the
Rooms must be separated by built-in neighborhood
1950 to 1959 archways or walls that extend out at least
Gas: bottled, tank, or LP
1940 to 1949 6 inches and go from floor to ceiling.
Electricity
1939 or earlier • INCLUDE bedrooms, kitchens, etc.
Fuel oil, kerosene, etc.
• EXCLUDE bathrooms, porches, balconies,
foyers, halls, or unfinished basements. Coal or coke
3 Wood
Number of rooms
When did PERSON 1 (listed on page 2)
move into this house, apartment, or Solar energy
mobile home?
Other fuel
Month Year
No fuel used
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".
Number of bedrooms
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107
APPENDIX B
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191069
Housing (continued)
11 a. LAST MONTH, what was the cost 12 IN THE PAST 12 MONTHS, did anyone in
C Answer questions 16 – 20 if you or
of electricity for this house, this household receive Food Stamps or
someone else in this household OWNS
apartment, or mobile home? a Food Stamp benefit card? Include
or IS BUYING this house, apartment, or
government benefits from the Supplemental
Last month’s cost – Dollars mobile home. Otherwise, SKIP to E on
Nutrition Assistance Program (SNAP).
the next page.
Do NOT include WIC or the National School
$ .00 Lunch Program.
,
OR Yes
Included in rent or condominium fee No 16 About how much do you think this
No charge or electricity not used house and lot, apartment, or mobile
home (and lot, if owned) would sell for
13 Is this house, apartment, or mobile home
if it were for sale?
b. LAST MONTH, what was the cost part of a condominium?
of gas for this house, apartment,
Amount – Dollars
or mobile home? Yes ➔ What is the monthly
condominium fee? For renters,
Last month’s cost – Dollars $ .00
answer only if you pay the , ,
condominium fee in addition to
$ .00
your rent; otherwise, mark the
,
17 What are the annual real estate taxes on
"None" box.
OR
THIS property?
Monthly amount – Dollars
Included in rent or condominium fee
Annual amount – Dollars
Included in electricity payment $ .00
,
entered above $ .00
,
No charge or gas not used OR
OR
None
c. IN THE PAST 12 MONTHS, what was
No None
the cost of water and sewer for this
house, apartment, or mobile home? If
14 Is this house, apartment, or mobile home –
you have lived here less than 12 months,
estimate the cost. Mark (X) ONE box. 18 What is the annual payment for fire,
hazard, and flood insurance on THIS
Past 12 months’ cost – Dollars Owned by you or someone in this property?
household with a mortgage or
$ .00 Annual amount – Dollars
loan? Include home equity loans.
,
Owned by you or someone in this
OR $ .00
household free and clear (without a ,
mortgage or loan)?
Included in rent or condominium fee
Rented?
No charge OR
Occupied without payment of None
d. IN THE PAST 12 MONTHS, what was the rent? ➔ SKIP to C
cost of oil, coal, kerosene, wood, etc.,
for this house, apartment, or mobile
B
home? If you have lived here less than 12 Answer questions 15a and b if this house,
months, estimate the cost. apartment, or mobile home is RENTED.
Otherwise, SKIP to question 16.
Past 12 months’ cost – Dollars
$ .00
,
15 a. What is the monthly rent for this
OR house, apartment, or mobile home?
Monthly amount – Dollars
Included in rent or condominium fee
No charge or these fuels not used
$ .00
,
b. Does the monthly rent include any
meals?
Yes
No
§.4+f¤
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108 SMALL POPULATIONS, LARGE EFFECTS
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13191077
Housing (continued)
19 a. Do you or any member of this 20 a. Do you or any member of this
E Answer questions about PERSON 1 on the
household have a second mortgage
household have a mortgage, deed of
next page if you listed at least one person
or a home equity loan on THIS
trust, contract to purchase, or similar
on page 2. Otherwise, SKIP to page 28 for
property?
debt on THIS property?
the mailing instructions.
Yes, mortgage, deed of trust, or similar Yes, home equity loan
debt
Yes, second mortgage
Yes, contract to purchase
Yes, second mortgage and home
No ➔ SKIP to question 20a equity loan
No ➔ SKIP to D
b. How much is the regular monthly
mortgage payment on THIS property? b. How much is the regular monthly
Include payment only on FIRST mortgage payment on all second or junior
or contract to purchase. mortgages and all home equity loans
on THIS property?
Monthly amount – Dollars
Monthly amount – Dollars
$ .00
, $ .00
,
OR
OR
No regular payment required ➔ SKIP to
question 20a No regular payment required
c. Does the regular monthly mortgage
payment include payments for real
estate taxes on THIS property?
D Answer question 21 if this is a MOBILE
HOME. Otherwise, SKIP to E .
Yes, taxes included in mortgage
payment
No, taxes paid separately or taxes
not required
21 What are the total annual costs for
personal property taxes, site rent,
d. Does the regular monthly mortgage
registration fees, and license fees on
payment include payments for fire,
THIS mobile home and its site?
hazard, or flood insurance on THIS
Exclude real estate taxes.
property?
Annual costs – Dollars
Yes, insurance included in mortgage
payment
$ .00
No, insurance paid separately or no ,
insurance
§.4+n¤ 7
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109
APPENDIX B
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191085
Person 1 11 What is the highest degree or level of school 13 What is this person’s ancestry or ethnic origin?
this person has COMPLETED? Mark (X) ONE box.
If currently enrolled, mark the previous grade or
➜ Please copy the name of Person 1 from page 2, highest degree received.
then continue answering questions below.
NO SCHOOLING COMPLETED
Last Name
(For example: Italian, Jamaican, African Am.,
No schooling completed
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
NURSERY OR PRESCHOOL THROUGH GRADE 12
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
First Name MI Nursery school
14 a. Does this person speak a language other than
Kindergarten
English at home?
Grade 1 through 11 – Specify
7 Where was this person born? grade 1 – 11
Yes
In the United States – Print name of state.
No ➔ SKIP to question 15a
b. What is this language?
12th grade – NO DIPLOMA
Outside the United States – Print name of HIGH SCHOOL GRADUATE
foreign country, or Puerto Rico, Guam, etc.
Regular high school diploma
For example: Korean, Italian, Spanish, Vietnamese
GED or alternative credential
c. How well does this person speak English?
COLLEGE OR SOME COLLEGE
8 Is this person a citizen of the United States?
Very well
Some college credit, but less than 1 year of
Yes, born in the United States ➔ SKIP to 10a
college credit Well
Yes, born in Puerto Rico, Guam, the 1 or more years of college credit, no degree Not well
U.S. Virgin Islands, or Northern Marianas
Associate’s degree (for example: AA, AS)
Yes, born abroad of U.S. citizen parent Not at all
or parents Bachelor’s degree (for example: BA, BS)
Yes, U.S. citizen by naturalization – Print year 15 a. Did this person live in this house or apartment
AFTER BACHELOR’S DEGREE
of naturalization 1 year ago?
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA) Person is under 1 year old ➔ SKIP to
question 16
Professional degree beyond a bachelor’s degree
No, not a U.S. citizen (for example: MD, DDS, DVM, LLB, JD) Yes, this house ➔ SKIP to question 16
Doctorate degree (for example: PhD, EdD)
9 No, outside the United States and
When did this person come to live in the
Puerto Rico – Print name of foreign country,
United States? Print numbers in boxes.
or U.S. Virgin Islands, Guam, etc., below;
Year then SKIP to question 16
F Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
10 a. At any time IN THE LAST 3 MONTHS, has this SKIP to question 13.
No, different house in the United States or
person attended school or college? I nclude Puerto Rico
only nursery or preschool, kindergarten,
elementary school, home school, and schooling
b. Where did this person live 1 year ago?
which leads to a high school diploma or a college
degree. Address (Number and street name)
12 This question focuses on this person’s
No, has not attended in the last 3 BACHELOR’S DEGREE. Please print below the
months ➔ SKIP to question 11 specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
Yes, public school, public college
engineering, elementary teacher education,
Yes, private school, private college, organizational psychology)
Name of city, town, or post office
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
Nursery school, preschool
Name of U.S. county or
municipio in Puerto Rico
Kindergarten
Grade 1 through 12 – Specify
grade 1 – 12
Name of U.S. state or
Puerto Rico ZIP Code
College undergraduate years (freshman to
senior)
Graduate or professional school beyond a
bachelor’s degree (for example: MA or PhD
program, or medical or law school)
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110 SMALL POPULATIONS, LARGE EFFECTS
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13191093
Person 1 (continued) c. How long has this grandparent been
H Answer question 19 if this person is responsible for these grandchildren?
15 years old or over. Otherwise, SKIP to If the grandparent is financially responsible for
16 Is this person CURRENTLY covered by any of the the questions for Person 2 on page 12. more than one grandchild, answer the question
following types of health insurance or health for the grandchild for whom the grandparent has
coverage plans? Mark "Yes" or "No" for EACH type been responsible for the longest period of time.
of coverage in items a – h. 19 Because of a physical, mental, or emotional Less than 6 months
condition, does this person have difficulty
Yes No
a. Insurance through a current or doing errands alone such as visiting a doctor’s 6 to 11 months
former employer or union (of this office or shopping?
person or another family member) 1 or 2 years
b. Insurance purchased directly from Yes 3 or 4 years
an insurance company (by this
person or another family member) No 5 or more years
c. Medicare, for people 65 and older, 20 What is this person’s marital status?
or people with certain disabilities 26 Has this person ever served on active duty in the
U.S. Armed Forces, military Reserves, or National
Now married
d. Medicaid, Medical Assistance, or Guard? Active duty does not include training for the
any kind of government-assistance
Widowed Reserves or National Guard, but DOES include
plan for those with low incomes activation, for example, for the Persian Gulf War.
or a disability Divorced
Yes, now on active duty
Separated
e. TRICARE or other military health care
Yes, on active duty during
Never married ➔ SKIP to I
f. VA (including those who have ever the last 12 months, but not now
used or enrolled for VA health care)
21 In the PAST 12 MONTHS did this person get – Yes, on active duty in the past, but not
g. Indian Health Service during the last 12 months
Yes No
No, training for Reserves or National Guard
h. Any other type of health insurance a. Married? only ➔ SKIP to question 28a
or health coverage plan – Specify
b. Widowed? No, never served in the military ➔ SKIP to
question 29a
c. Divorced?
27 When did this person serve on active duty in the
U.S. Armed Forces? Mark (X) a box for EACH period
22 How many times has this person been married?
17 a. Is this person deaf or does he/she have in which this person served, even if just for part of the
period.
serious difficulty hearing?
Once
September 2001 or later
Two times
Yes
August 1990 to August 2001 (including
Three or more times
No Persian Gulf War)
b. Is this person blind or does he/she have 23 In what year did this person last get married? September 1980 to July 1990
serious difficulty seeing even when wearing
glasses? May 1975 to August 1980
Year
Vietnam era (August 1964 to April 1975)
Yes
March 1961 to July 1964
No
February 1955 to February 1961
I Answer question 24 if this person is
G Answer question 18a – c if this person is Korean War (July 1950 to January 1955)
female and 15 – 50 years old. Otherwise,
5 years old or over. Otherwise, SKIP to SKIP to question 25a. January 1947 to June 1950
the questions for Person 2 on page 12.
World War II (December 1941 to December 1946)
24 Has this person given birth to any children in November 1941 or earlier
18 a. Because of a physical, mental, or emotional the past 12 months?
condition, does this person have serious
28 a. Does this person have a VA service-connected
difficulty concentrating, remembering, or Yes disability rating?
making decisions?
No
Yes (such as 0%, 10%, 20%, ... , 100%)
Yes 25 a. Does this person have any of his/her own
No ➔ SKIP to question 29a
grandchildren under the age of 18 living in
No
this house or apartment?
b. Does this person have serious difficulty b. What is this person’s service-connected
walking or climbing stairs? Yes disability rating?
No ➔ SKIP to question 26
Yes 0 percent
b. Is this grandparent currently responsible for
No 10 or 20 percent
most of the basic needs of any grandchildren
c. Does this person have difficulty dressing or under the age of 18 who lives in this house or 30 or 40 percent
bathing? apartment?
50 or 60 percent
Yes Yes 70 percent or higher
No No ➔ SKIP to question 26
9
99
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111
APPENDIX B
PREPUBLICATION COPY, UNCORRECTED PROOFS
13191101
Person 1 (continued) 36 During the LAST 4 WEEKS, has this person been
J Answer question 32 if you marked "Car,
ACTIVELY looking for work?
truck, or van" in question 31. Otherwise,
29 a. LAST WEEK, did this person work for pay SKIP to question 33. Yes
at a job (or business)?
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
32 How many people, including this person,
No – Did not work (or retired)
usually rode to work in the car, truck, or van 37 LAST WEEK, could this person have started a
LAST WEEK? job if offered one, or returned to work if
b. LAST WEEK, did this person do ANY work
recalled?
Person(s)
for pay, even for as little as one hour?
Yes, could have gone to work
Yes
No, because of own temporary illness
No ➔ SKIP to question 35a
No, because of all other reasons (in school, etc.)
33 What time did this person usually leave home
30 At what location did this person work LAST to go to work LAST WEEK?
WEEK? If this person worked at more than one 38 When did this person last work, even for a few
Hour Minute
location, print where he or she worked most
days?
a.m.
last week.
:
a. Address (Number and street name) p.m. Within the past 12 months
1 to 5 years ago ➔ SKIP to L
Over 5 years ago or never worked ➔ SKIP to
34 How many minutes did it usually take this question 47
If the exact address is not known, give a person to get from home to work LAST WEEK?
description of the location such as the building
name or the nearest street or intersection. Minutes 39 a. During the PAST 12 MONTHS (52 weeks), did
this person work 50 or more weeks? Count
b. Name of city, town, or post office
paid time off as work.
Yes ➔ SKIP to question 40
No
K Answer questions 35 – 38 if this person
c. Is the work location inside the limits of that
did NOT work last week. Otherwise,
city or town?
b. How many weeks DID this person work, even
SKIP to question 39a.
for a few hours, including paid vacation, paid
Yes
sick leave, and military service?
No, outside the city/town limits
50 to 52 weeks
35 a. LAST WEEK, was this person on layoff from
d. Name of county
a job? 48 to 49 weeks
40 to 47 weeks
Yes ➔ SKIP to question 35c
27 to 39 weeks
No
e. Name of U.S. state or foreign country
14 to 26 weeks
b. LAST WEEK, was this person TEMPORARILY 13 weeks or less
absent from a job or business?
f. ZIP Code Yes, on vacation, temporary illness, 40 During the PAST 12 MONTHS, in the WEEKS
maternity leave, other family/personal
WORKED, how many hours did this person
reasons, bad weather, etc. ➔ SKIP to
usually work each WEEK?
question 38
Usual hours worked each WEEK
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one c. Has this person been informed that he or she
method of transportation during the trip, mark (X)
will be recalled to work within the next
the box of the one used for most of the distance.
6 months OR been given a date to return to
work?
Car, truck, or van Motorcycle
Yes ➔ SKIP to question 37
Bus or trolley bus Bicycle
Streetcar or trolley car Walked No
Subway or elevated Worked at
home ➔ SKIP
Railroad to question 39a
Ferryboat Other method
Taxicab
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Person 1 (continued) 45 What kind of work was this person doing? d. Social Security or Railroad Retirement.
(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant) $ .00
Yes ➔
L Answer questions 41 – 46 if this person ,
worked in the past 5 years. Otherwise, No
TOTAL AMOUNT for past
SKIP to question 47.
12 months
e. Supplemental Security Income (SSI).
46 What were this person’s most important
41 – 46 CURRENT OR MOST RECENT JOB
activities or duties? (For example: patient care,
ACTIVITY. Describe clearly this person’s chief
directing hiring policies, supervising order clerks,
job activity or business last week. If this person
$ .00
Yes ➔
typing and filing, reconciling financial records)
had more than one job, describe the one at ,
which this person worked the most hours. If this No
person had no job or business last week, give TOTAL AMOUNT for past
information for his/her last job or business. 12 months
41 Was this person – f. Any public assistance or welfare payments
Mark (X) ONE box. 47 INCOME IN THE PAST 12 MONTHS from the state or local welfare office.
an employee of a PRIVATE FOR-PROFIT Mark (X) the "Yes" box for each type of income this
company or business, or of an individual, for $ .00
Yes ➔
person received, and give your best estimate of the
,
wages, salary, or commissions? TOTAL AMOUNT during the PAST 12 MONTHS.
No
(NOTE: The "past 12 months" is the period from TOTAL AMOUNT for past
an employee of a PRIVATE NOT-FOR-PROFIT,
today’s date one year ago up through today.) 12 months
tax-exempt, or charitable organization?
Mark (X) the "No" box to show types of income
a local GOVERNMENT employee
g. Retirement, survivor, or disability pensions.
NOT received.
(city, county, etc.)?
Do NOT include Social Security.
a state GOVERNMENT employee? If net income was a loss, mark the "Loss" box to
the right of the dollar amount. $ .00
Yes ➔
a Federal GOVERNMENT employee?
,
For income received jointly, report the appropriate No
SELF-EMPLOYED in own NOT INCORPORATED
TOTAL AMOUNT for past
share for each person – or, if that’s not possible,
business, professional practice, or farm?
12 months
report the whole amount for only one person and
mark the "No" box for the other person.
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm? h. Any other sources of income received
a. Wages, salary, commissions, bonuses, regularly such as Veterans’ (VA) payments,
working WITHOUT PAY in family business
or tips from all jobs. Report amount before unemployment compensation, child support
or farm?
or alimony. Do NOT include lump sum payments
deductions for taxes, bonds, dues, or other items.
such as money from an inheritance or the sale of a
42 For whom did this person work? home.
$ .00
Yes ➔
If now on active duty in ,
the Armed Forces, mark (X) this box ➔ No $ .00
Yes ➔
TOTAL AMOUNT for past
and print the branch of the Armed Forces. ,
12 months No
Name of company, business, or other employer TOTAL AMOUNT for past
12 months
b. Self-employment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships. Report 48 What was this person’s total income during the
NET income after business expenses. PAST 12 MONTHS? Add entries in questions 47a
to 47h; subtract any losses. If net income was a loss,
43 What kind of business or industry was this?
enter the amount and mark (X) the "Loss" box next to
Describe the activity at the location where employed.
$ .00
Yes ➔ the dollar amount.
(For example: hospital, newspaper publishing, mail ,
order house, auto engine manufacturing, bank)
No Loss
TOTAL AMOUNT for past None OR $ .00
12 months , ,
Loss
TOTAL AMOUNT for past
c. Interest, dividends, net rental income, 12 months
royalty income, or income from estates
44 Is this mainly – Mark (X) ONE box. and trusts. Report even small amounts credited
to an account.
manufacturing?
wholesale trade? $ .00
Yes ➔
,
retail trade? No Loss
TOTAL AMOUNT for past
other (agriculture, construction, service, 12 months
government, etc.)?
➜ Continue with the questions for Person 2 on
the next page. If no one is listed as person 2 on
page 2, SKIP to page 28 for mailing instructions.
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APPENDIX B
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13191127
Person 2
The balance of the questionnaire
has questions for Person 2,
Person 3, Person 4, and Person 5.
The questions are the same as
the questions for Person 1.
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114 SMALL POPULATIONS, LARGE EFFECTS
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115
APPENDIX B
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13191283
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• 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.
The Census Bureau estimates that, for the average
household, this form will take 38 minutes to complete,
including the time for reviewing the instructions and
For Census Bureau Use 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 0607-0810, U.S. Census Bureau,
POP EDIT PHONE JIC1 JIC2 4600 Silver Hill Road, AMSD – 3K138, Washington, D.C.
20233. You may e-mail comments to
Paperwork@census.gov; use "Paperwork Project
0607-0810" as the subject. Please DO NOT RETURN
your questionnaire to this address. Use the enclosed
EDIT CLERK TELEPHONE CLERK JIC3 JIC4 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(INFO)(2011)KFI (06-14-2010)
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