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Appendix C
2011 American Community Survey:
Group Quarters Questionnaire
117
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118 SMALL POPULATIONS, LARGE EFFECTS
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13261011
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.
This questionnaire is available in either English or Spanish.
Este cuestionario está disponible en español o en inglés.
Para completar cuestionario en inglés, comience en
To complete the English questionnaire, begin on
la página 2. Para completar el cuestionario en
page 2. To complete the Spanish questionnaire, flip
español, vírelo y complete el lado verde.
this over and complete the green side.
Por favor, complete este cuestionario tan
Please complete this form as soon as possible.
pronto sea posible. Colóquelo en el sobre que se
Place it in the envelope provided and HOLD it for a
provee y GUÁRDELO hasta que un representante del
census representative to return to pick it up.
censo lo venga a recoger.
If you need help or have questions about Si necesita ayuda o tiene preguntas sobre cómo
completing this form, call the number that our completar este cuestionario, llame al número de
census representative has given you. teléfono que le ha dado nuestro representante del
censo.
For more information about the American
Para obtener más información sobre la Encuesta
Community Survey, visit our web site at:
sobre la Comunidad Estadounidense, vaya a nuestra
http://www.census.gov/acs.
página en la Internet: http://www.census.gov/acs.
How was this form completed?
CENSUS USE ONLY English Spanish
OMB No. 0607-0810
ACS-1(GQ)(2011)
FORM
(09-08-2010)
USCENSUSBUREAU
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119
APPENDIX C
PREPUBLICATION COPY, UNCORRECTED PROOFS
13261029
1 What is your name? Please print your name. 5 7 Are you a citizen of the United States?
What is your race? Mark (✗) one or more
Include your telephone number, and today’s boxes.
B
date so we can contact you if there is a question. Yes, born in the United States ➔ SKIP to
question 9a
White
Last Name
Yes, born in Puerto Rico, Guam, the
Black, African Am., or Negro
U.S. Virgin Islands, or Northern Marianas
American Indian or Alaska Native – Print Yes, born abroad of U.S. citizen parent or
name of enrolled or principal tribe. parents
First Name MI
Yes, U.S. citizen by naturalization – Print
year of naturalization
Area Code + Number
Asian Indian Native Hawaiian
— No, not a U.S. citizen
Chinese Guamanian
or Chamorro
Filipino
Today’s Date
Samoan 8 When did you come to live in the
Month Day Year Japanese United States? Print numbers in boxes.
Other Pacific
Korean Islander – Print Year
race, for example,
Vietnamese
Fijian, Tongan,
and so on.
Other Asian – Print race,
2 What is your sex? Mark (✗) ONE box. for example, Hmong,
Laotian, Thai, Pakistani,
Male Female Cambodian, and so on.
9 a. At any time IN THE LAST 3 MONTHS, have
you attended school or college? Include
only nursery or preschool, kindergarten,
3 What is your age and what is your date of elementary school, home school, and schooling
birth? Please report babies as age 0 when the which leads to a high school diploma or a
child is less than 1 year old. college degree.
Print numbers in boxes. Some other race – Print race. No, have not attended in the last 3
Age (in years) Month Day Year of birth
months ➔ SKIP to question 10
Yes, public school, public college
Yes, private school, private college,
home school
A NOTE: Please answer BOTH Question 4 b. What grade or level were you attending?
6 Where were you born?
about Hispanic origin and Question 5 Mark (✗) ONE box.
about race. For this survey, Hispanic
In the United States – Print name of state.
origins are not races. Nursery school, preschool
Kindergarten
Grade 1 through 12 – Specify
4 Are you of Hispanic, Latino, or Spanish grade 1 - 12
origin? Outside the United States – Print name
A of foreign country, or Puerto Rico,
No, not of Hispanic, Latino, or Guam, etc.
Spanish origin
Yes, Mexican, Mexican Am., Chicano College undergraduate years (freshman
to senior)
Yes, Puerto Rican
Graduate or professional school beyond
Yes, Cuban
a bachelor’s degree (for example: MA or
PhD program, or medical or law school)
Yes, another Hispanic, Latino, or Spanish
origin – Print origin, for example,
Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and
so on.
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10 What is the highest degree or level of 12 What is your ancestry or ethnic origin? 15 IN THE PAST 12 MONTHS, did you receive
school you have COMPLETED? Mark (✗) Food Stamps or a Food Stamp benefit card?
ONE box. If currently enrolled, mark the Include government benefits from the
previous grade or highest degree received. Supplemental Nutrition Assistance Program
(SNAP). Do NOT include WIC or the National
C
NO SCHOOLING COMPLETED School Lunch Program.
(For example: Italian, Jamaican, African Am.,
No schooling completed
Yes
Cambodian, Cape Verdean, Norwegian,
Dominican, French Canadian, Haitian, Korean,
NURSERY OR PRESCHOOL THROUGH GRADE 12
No
Lebanese, Polish, Nigerian, Mexican, Taiwanese,
Nursery school Ukrainian, and so on.)
16 Are you CURRENTLY covered by any of the
13 a. Do you speak a language other than
Kindergarten following types of health insurance or
English at home? health coverage plans? Mark "Yes" or "No"
Grade 1 through 11 – Specify
for EACH type of coverage in items a – h.
grade 1 – 11
Yes
Yes No
a. Insurance through a current
No ➔ SKIP to question 14a
or former employer or union
(of yours or another family
b. What is this language?
12th grade – NO DIPLOMA member)
b. Insurance purchased directly
HIGH SCHOOL GRADUATE
from an insurance company
Regular high school diploma For example: Korean, Italian, Spanish, Vietnamese (by you or another family
member)
c. How well do you speak English?
GED or alternative credential
c. Medicare, for people 65 and
Very well
COLLEGE OR SOME COLLEGE
older, or people with certain
Well
Some college credit, but less than 1 year of disabilities
college credit
Not well
d. Medicaid, Medical Assistance,
1 or more years of college credit, no degree
Not at all or any kind of government-
Associate’s degree (for example: AA, AS) assistance plan for those with
14 a. Did you live at this address 1 year ago? low incomes or a disability
Bachelor’s degree (for example: BA, BS)
Person is under 1 year old ➔ SKIP to e. TRICARE or other
AFTER BACHELOR’S DEGREE
question 16 military health care
Master’s degree (for example: MA, MS, Yes, at this address ➔ SKIP to
MEng, MEd, MSW, MBA) question 15 f. VA (including if you have
Professional degree beyond a bachelor’s ever used or enrolled for
No, outside the United States and
degree (for example: MD, DDS, DVM, LLB, VA health care)
Puerto Rico – Print name of foreign
JD) country, or U.S. Virgin Islands, Guam,
Doctorate degree (for example: PhD, EdD) etc., below; then SKIP to question 15 g. Indian Health Service
h. Any other type of health
insurance or health coverage
B No, at a different address in the plan – Specify
Answer question 11 if you have a bachelor’s
United States or Puerto Rico
degree or higher. Otherwise, SKIP to
question 12. b. Where did you live 1 year ago?
Address (Number and street name)
11 This question focuses on your BACHELOR’S
DEGREE. Please print below the specific
major(s) of any BACHELOR’S DEGREES you
have received. (For example: chemical Name of city, town, post office, military
engineering, elementary teacher education, installation, or base
organizational psychology)
Name of U.S. county or
municipio in Puerto Rico
Name of U.S. state or
Puerto Rico ZIP Code
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121
APPENDIX C
PREPUBLICATION COPY, UNCORRECTED PROOFS
13261045
17 a. Are you deaf or do you have serious 20 What is your marital status? 26 Have you ever served on active duty in the
difficulty hearing? U.S. Armed Forces, military Reserves, or
National Guard? Active duty does not include
Now married
training for the Reserves or National Guard, but
Yes Widowed DOES include activation, for example, for the
No Persian Gulf War.
Divorced
Separated Yes, now on active duty
b. Are you blind or do you have serious
Never married ➔ SKIP to E
difficulty seeing even when wearing Yes, on active duty during the last 12
glasses? months, but not now
21 In the PAST 12 MONTHS did you get – Yes, on active duty in the past, but not
Yes Yes No during the last 12 months
No No, training for Reserves or National Guard
a. Married?
only ➔ SKIP to question 28a
b. Widowed? No, never served in the military ➔ SKIP to
C Answer question 18a – c if you are 5 years
question 29a
old or over. Otherwise, SKIP to I on page c. Divorced?
7 for further instructions; do not answer
22 How many times have you been married?
any more questions.
27 When did you serve on active duty in the
U.S. Armed Forces? Mark (✗) a box for EACH
Once
period in which you served, even if just for part
Two times of the period.
18 a. Because of a physical, mental, or D
emotional condition, do you have Three or more times September 2001 or later
serious difficulty concentrating,
remembering, or making decisions? August 1990 to August 2001 (including
23 In what year did you last get married?
Persian Gulf War)
Yes Year
September 1980 to July 1990
No
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
b. Do you have serious difficulty walking
E
or climbing stairs? March 1961 to July 1964
Answer question 24 if you are female and
15 – 50 years old. Otherwise, SKIP to question
Yes February 1955 to February 1961
25a.
No Korean War (July 1950 to January 1955)
January 1947 to June 1950
24 Have you given birth to any children in the
c. Do you have difficulty dressing or
past 12 months? World War II (December 1941 to
bathing?
December 1946)
Yes
Yes November 1941 or earlier
No
No
25 a. Do you have any of your own 28 a. Do you have a VA service-connected
grandchildren under the age of 18
D disability rating?
Answer question 19 if you are 15 years old
living in this place?
or over. Otherwise, SKIP to I on page 7
Yes (such as 0%, 10%, 20%, ... , 100%)
for further instructions; do not answer any Yes
more questions. No ➔ SKIP to question 29a
No ➔ SKIP to question 26
b. What is your service-connected
b. Are you currently responsible for most
disability rating?
of the basic needs of any grandchildren
19 Because of a physical, mental, or emotional
under the age of 18 who lives in this
condition, do you have difficulty doing
0 percent
place?
errands alone such as visiting a doctor’s
office or shopping? 10 or 20 percent
Yes
30 or 40 percent
Yes No ➔ SKIP to question 26
50 or 60 percent
No
c. How long have you been responsible
70 percent or higher
for these grandchildren? If you are
financially responsible for more than one
grandchild, answer the question for the
grandchild for whom you have been
responsible for the longest period of time.
Less than 6 months 3 or 4 years
6 to 11 months 5 or more
years
1 or 2 years
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29 a. LAST WEEK, did you work for pay at a 36 During the LAST 4 WEEKS, have you been
F Answer question 32 if you marked "Car,
job (or business)? ACTIVELY looking for work?
truck, or van" in question 31. Otherwise,
SKIP to question 33.
Yes
Yes ➔ SKIP to question 30
No ➔ SKIP to question 38
No – Did not work (or retired)
32 How many people, including yourself,
usually rode to work in the car, truck, or
b. LAST WEEK, did you do ANY work for 37 LAST WEEK, could you have started a job if
van LAST WEEK?
pay, even for as little as one hour? offered one, or returned to work if recalled?
Person(s)
Yes Yes, could have gone to work
No ➔ SKIP to question 35a No, because of own temporary illness
No, because of all other reasons
30 At what location did you work LAST (in school, etc.)
WEEK? If you worked at more than one 33 What time did you usually leave this
location, print where you worked most address to go to work LAST WEEK?
38 When did you last work, even for a
last week.
few days?
Hour Minute
a. Address (Number and street name) a.m.
: Within the past 12 months
p.m.
1 to 5 years ago ➔ SKIP to H
Over 5 years ago or never worked ➔ SKIP
If the exact address is not known, give a
description of the location such as the building 34 How many minutes did it usually take to question 47
you to get from this address to work
name or the nearest street or intersection.
LAST WEEK? 39 a. During the PAST 12 MONTHS (52 weeks),
b. Name of city, town, post office, military did you work 50 or more weeks? Count
Minutes
installation, or base paid time off as work.
Yes ➔ SKIP to question 40
No
c. Is the work location inside the limits of
G
that city or town? Answer questions 35 – 38 if you did NOT b. How many weeks DID you work, even
work last week. Otherwise, SKIP to question for a few hours, including paid vacation,
Yes 39a. paid sick leave, and military service?
No, outside the city/town limits
50 to 52 weeks
d. Name of county 35 a. LAST WEEK, were you on layoff from 48 to 49 weeks
a job? 40 to 47 weeks
Yes ➔ SKIP to question 35c 27 to 39 weeks
No 14 to 26 weeks
e. Name of U.S. state or foreign country
13 weeks or less
b. LAST WEEK, were you TEMPORARILY
absent from a job or business?
40 During the PAST 12 MONTHS, in the WEEKS
Yes, on vacation, temporary illness, WORKED, how many hours did you usually
f. ZIP Code
maternity leave, other family/personal work each WEEK?
reasons, bad weather, etc. ➔ SKIP to
Usual hours worked each WEEK
question 38
No ➔ SKIP to question 36
31 How did you usually get to work LAST c. Have you been informed that you will be
WEEK? If you usually used more than one recalled to work within the next 6 months
method of transportation during the trip, OR been given a date to return to work?
mark (✗) the box of the one used for most
of the distance. E Yes ➔ SKIP to question 37
Car, truck, or van Motorcycle No
Bus or trolley bus Bicycle
Streetcar or Walked
trolley car
Worked at this
Subway or elevated address ➔ SKIP
to question 39a
Railroad
Other method
Ferryboat
Taxicab
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APPENDIX C
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45 What kind of work were you doing? (For d. Did you receive any Social Security or
H Answer questions 41 – 46 if you worked in Railroad Retirement income in the PAST
example: registered nurse, personnel manager,
the past 5 years. Otherwise, SKIP to 12 MONTHS?
supervisor of order department, secretary,
question 47. accountant)
Yes ➔ What was the amount?
Total amount - Dollars
41–46 CURRENT OR MOST RECENT JOB ACTIVITY
Describe clearly your chief job activity or $ .00
business last week. If you had more than one ,
job, describe the one at which you worked the 46 What were your most important activities
or duties? (For example: patient care, directing No
most hours. If you did not have a job or
hiring policies, supervising order clerks, typing
business last week, give information for your
e. Did you receive any Supplemental
and filing, reconciling financial records)
last job or business.
Security Income (SSI) in the PAST 12
MONTHS?
41 Were you –
F
Mark (✗) ONE box. Yes ➔ What was the amount?
Total amount - Dollars
47 INCOME IN THE PAST 12 MONTHS
an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual,
Mark (✗) the "Yes" box for each type of income $ .00
for wages, salary, or commissions?
you received, and give your best estimate of the ,
an employee of a PRIVATE NOT-FOR-PROFIT, TOTAL AMOUNT during the PAST 12 MONTHS. No
tax-exempt, or charitable organization? (NOTE: The "past 12 months" is the period from
a local GOVERNMENT employee (city, today’s date one year ago up through today.) f. Did you receive any public assistance or
county, etc.)? welfare payments from the state or local
Mark (✗) the "No" box to show types of income
a state GOVERNMENT employee? welfare office in the PAST 12 MONTHS?
NOT received.
If your net income was a loss, mark the "Loss"
a Federal GOVERNMENT employee? Yes ➔ What was the amount?
box to the right of the dollar amount.
SELF-EMPLOYED in own NOT Total amount - Dollars
For income received jointly, report only your
INCORPORATED business, professional
share of the amount received or earned.
practice, or farm? $ .00
,
SELF-EMPLOYED in own INCORPORATED a. Did you receive any wages, salary,
business, professional practice, or farm? No
commissions, bonuses, or tips in the
PAST 12 MONTHS?
working WITHOUT PAY in family business
g. Did you receive any retirement, survivor,
or farm?
or disability pensions in the PAST 12
Yes ➔ What was the amount from
MONTHS? Do NOT include Social Security.
all jobs before deductions for
42 For whom did you work? taxes, bonds, dues, or other
Yes ➔ What was the amount?
If now on active duty in items?
the Armed Forces, mark (✗) this box ➜ Total amount - Dollars
Total amount - Dollars
and print the branch of the Armed Forces.
$ .00
Name of company, business, or other employer $ .00 ,
,
No
No
h. Did you have any other sources of income
b. Did you have any self-employment received regularly such as Veterans’ (VA)
income from own nonfarm businesses
43 What kind of business or industry was this? payments, unemployment compensation,
or farm businesses, including child support, or alimony in the PAST 12
Describe the activity at the location where
proprietorships and partnerships, MONTHS? Do NOT include lump sum
employed. (For example: hospital, newspaper
in the PAST 12 MONTHS?
publishing, mail order house, auto engine payments such as money from an inheritance
manufacturing, bank) or sale of a home.
Yes ➔ What was the net income
after business expenses?
Yes ➔ What was the amount?
Total amount - Dollars Total amount - Dollars
Loss
$ .00 $ .00
, ,
44 Is this mainly – Mark (✗) ONE box.
No No
manufacturing?
c. Did you receive any interest, dividends,
wholesale trade? net rental income, royalty income, or 48 What was your total income during the
income from estates and trusts in the PAST 12 MONTHS? Add entries 47a–47h;
retail trade?
PAST 12 MONTHS? Report even small subtract any losses. If net income was a loss,
other (agriculture, construction, service, amounts credited to an account. enter the amount and mark (✗) the "Loss" box
government, etc.)? next to the dollar amount.
Yes ➔ What was the amount?
Total amount - Dollars
Total amount - Dollars
Loss
Loss
$ .00
$ .00 None , ,
, OR
No
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13261078
I Thank you very much for your
participation.
Place the questionnaire in the
envelope and HOLD for your Census
Bureau Representative to pick up.
The Census Bureau estimates that this form will take about 25 minutes to complete, including the time for reviewing the instructions and answers. Send
comments regarding this burden estimate, including suggestions for reducing this burden, to: Paperwork Reduction Project 0607-0810, U.S. Census Bureau,
4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may email comments to Paperwork@census.gov; use "Paperwork Project 0607-0810" as
the subject.
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.
§.;+o¤ 7
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