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Appendix B 2011 American Community Survey: Housing Unit Questionnaire 101

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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) §.4++¤ 91

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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+=¤ 2 92

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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 93

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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) §.4+M¤ 4 94

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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 §.4+T¤ 5 95

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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¤ 6 96

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108 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 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 97

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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) §.4+v¤ 8 98

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110 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 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 §.4,"¤ 10 100

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112 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13191119 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. §.4,4¤ 11 101

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113 APPENDIX B PREPUBLICATION COPY, UNCORRECTED PROOFS 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. §.4,<¤ 12 102

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114 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13191275 §.4-l¤ 27 103

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115 APPENDIX B PREPUBLICATION COPY, UNCORRECTED PROOFS 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) §.4-t¤ 28 104

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