D-20 PI Individual Census Report, Pacific Islands

DRAFT #2 (1-21-2009)

Pacific Islands

Individual
Census
Report

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Use a blue or black pen.

Start here
1.

4.

-

What is your name? Print name below.
Last Name

5.
First Name

-

What is your sex? Mark ✗ ONE box.
Male
Female

MI

6.
2.

What is your telephone number? We may call
you if we don’t understand an answer.
Area Code + Number

Do you live or stay in this facility MOST OF
THE TIME?

What is your age and what is your date of
birth? Please report babies as age 0 when the child
is less than 1 year old.
Age on April 1, 2010

Yes – SKIP to question 4
No

3.

Print numbers in boxes.
Month
Day
Year of birth

What is the address of the place where you
live or stay MOST OF THE TIME? Please
complete all that apply.
Development/Building name or Subdivision/Place name

7.

What is your ethnic origin or race?

House number

Apartment number

Street or Road name

(For example: Chamorro, Samoan, White, Black,
Carolinian, Filipino, Japanese, Korean, Palauan,
Tongan, and so on.)

8.

Where were you born? Print the name of the
island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

9.

Are you a CITIZEN or NATIONAL of the
United States?

Physical description/Location

Yes, born in this area of current residence
(American Samoa, Guam, or Northern Mariana
Islands) – SKIP to question 12a
District/Municipality/Village

ZIP Code

Yes, born in the United States or another
U.S. territory or commonwealth
Yes, born elsewhere of U.S. parent or parents
Yes, a U.S. citizen by naturalization
No, not a U.S. citizen or national (permanent
resident)
No, not a U.S. citizen or national (temporary
resident)
OMB No. 0000-0000: Approval Expires 00/00/0000

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10.

11.

14b. What grade or level were you attending?
When did you come to this area of current
residence to stay? If you have entered the
Mark ✗ ONE box.
area more than once, what is the latest year?
Pre-kindergarten
Print numbers in boxes.
Kindergarten
Year
Grade 1 through 12 –
Specify grade 1–12
College undergraduate years (freshman to senior)
What was your MAIN reason for moving to
Graduate or professional school beyond a
this area? Mark ✗ ONE box.
bachelor’s degree (for example, MA or PhD
program or medical or law school)
Employment
Military
15. What is the highest degree or level of
Subsistence activities
school you have COMPLETED? Mark ✗
Missionary activities
ONE box. If currently enrolled, mark the previous
grade or highest degree received.
Moved with spouse or parent
To attend school
NO SCHOOLING COMPLETED
Medical
No schooling completed
Housing
Other
PRE-KINDERGARTEN THROUGH GRADE 12

12a. Where was your mother born? Print the name
of the island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

Pre-kindergarten
Kindergarten
Grade 1 through 11 –
Specify grade 1–11
12th grade – NO DIPLOMA

b. Where was your father born? Print the name of
the island (village in American Samoa), U.S. state,
commonwealth, territory, or foreign country.

HIGH SCHOOL GRADUATE
Regular high school diploma
GED or alternative credential
COLLEGE OR SOME COLLEGE

13.

Are you a dependent of an active-duty or
retired member of the Armed Forces of the
United States or of the full-time military
Reserves or National Guard? Active duty does
NOT include training for the military Reserves or
National Guard.
Yes, dependent of an active-duty member of the
Armed Forces
Yes, dependent of retired member of the Armed
Forces, or dependent of an active-duty or retired
member of full-time National Guard or Armed
Forces Reserve
No

14a. At any time since February 1, 2010, have
you attended school or college? Include
only pre-kindergarten, kindergarten, elementary
school, home school, and schooling which leads to
a high school diploma or a college degree.
No, have not attended since February 1 – SKIP
to question 15
Yes, public school, public college
Yes, private school, private college, home school

Some college credit, but less than 1 year of
college credit
1 or more years of college credit, no degree
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
Master’s degree (for example: MA, MS, MEng,
MEd, MSW, MBA)
Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

16. Have you completed the requirements for a
vocational training program at a trade
school, business school, hospital, some
other kind of school for occupational
training, or place of work? Do not include
academic college courses.
No
Yes, in this area
Yes, not in this area

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17a. Do you speak a language other than
English at home?
Yes
No – SKIP to question 18a

b. What is this language?

(For example: Chamorro, Samoan, Carolinian, Tongan)

c. Do you speak this language at home more
frequently than English?
Yes, more frequently than English
Both equally often
No, less frequently than English
Does not speak English

18a. Did you live at this address 1 year ago
(on April 1, 2009)?
Person is under 1 year old – SKIP to question 19
Yes, at this address – SKIP to question 19
No, at a different address

19.

Are you CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH
type of coverage in items a–h.
Yes No
a. Insurance through a current or former
employer or union (of yours or
another family member) . . . . . . . . . . . .
b. Insurance purchased directly from an
insurance company (by you or
another family member) . . . . . . . . . . . .
c. Medicare, for people 65 and older, or
people with certain disabilities . . . . . . . .
d. Medicaid or any kind of federal
government assistance plan for those
with low incomes or a disability . . . . . . .
e. TRICARE or other military health care . .
f. VA (including those who have ever
used or enrolled for VA health care)

...

g. Local medical programs for indigents . . .
h. Any other type of health insurance or
health coverage plan – Specify

b. Where did you live 1 year ago?
What is the name of the island, U.S. state,
commonwealth, territory, or foreign
country?

c. What is the name of the city, town, or
village?

20a. Are you deaf or do you have serious
difficulty hearing?
Yes
No
b. Are you blind or do you have serious
difficulty seeing even when wearing
glasses?
Yes
No

Answer questions 21a–c if you are 5 years old or over.
Otherwise, SKIP to question 51.
21a. Because of a physical, mental, or
emotional condition, do you have serious
difficulty concentrating, remembering, or
making decisions?
Yes
No

b. Do you have serious difficulty walking or
climbing stairs?
Yes
No

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21c. Do you have difficulty dressing or
bathing?
Yes
No

Answer question 22 if you are 15 years old or over.
Otherwise, SKIP to question 51.
22.

Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
Yes
No

23.

What is your marital status?
Now married
Widowed
Divorced
Separated
Never married

24.

If you are female, how many babies have
you ever had, not counting stillbirths? Do
not count stepchildren or children you have
adopted.
None OR Number of children

25a. Do you have any of your own grandchildren
under the age of 18 living in this house,
apartment, dormitory, or institution?
Yes
No – SKIP to question 26

b. Are you currently responsible for most of
the basic needs of any grandchild(ren)
under the age of 18 who live(s) in this
house, apartment, dormitory, or
institution?
Yes
No – SKIP to question 26
c. How long have you been responsible for
the(se) grandchild(ren)? 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.

26. Have you ever served on active duty in
the U.S. Armed Forces, military Reserves,
or National Guard? Active duty does not
include training for the Reserves or National
Guard, but DOES include activation, for example,
for the Persian Gulf War.
Yes, now on active duty
Yes, on active duty during the last 12 months,
but not now
Yes, on active duty in the past, but not during
the last 12 months
No, training for Reserves or National Guard
only – SKIP to question 28a
No, never served in the military – SKIP to
question 29a

27. When did you serve on active duty in the
U.S. Armed Forces? Mark ✗ a box for EACH
period in which you served, even if just for part of
the period.
September 2001 or later
August 1990 to August 2001 (including
Persian Gulf War)
September 1980 to July 1990
May 1975 to August 1980
Vietnam era (August 1964 to April 1975)
March 1961 to July 1964
February 1955 to February 1961
Korean War (July 1950 to January 1955)
January 1947 to June 1950
World War II (December 1941 to December 1946)
November 1941 or earlier

28a. Do you have a VA service-connected
disability rating?
Yes (such as 0%, 10%, 20%, . . ., 100%)
No – SKIP to question 29a
b. What is your service-connected disability
rating?
0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

Less than 6 months
6 to 11 months
1 or 2 years
3 or 4 years
5 or more years

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29a. LAST WEEK, did you work for pay at a job
(or business)? If "Yes," also indicate whether
you did subsistence activity last week, such as
fishing, growing crops, etc., NOT primarily for
commercial purposes. Mark ✗ ONE box.
Yes, worked for pay; did NO subsistence
activity – SKIP to question 30
Yes, worked for pay AND did subsistence
activity – SKIP to question 30
No, did NOT work for pay at a job or business
(or was retired)

Answer question 32 if you marked "Car, truck, or
private van/bus" in question 31. Otherwise, SKIP to
question 33.
32.

How many people, including yourself,
usually rode to work in the car, truck, or
private van/bus LAST WEEK?
Person(s)

33.

What time did you usually leave this address
to go to work LAST WEEK?
Hour
Minute
a.m.
:
p.m.

b. LAST WEEK, did you do ANY work for pay,
even for as little as one hour? Mark ✗
ONE box.
Yes, worked for pay; did NO subsistence activity
Yes, worked for pay AND did subsistence activity 34.
No, did NOT work for pay; did subsistence
activity – SKIP to question 35a
No, did NOT work for pay; did NO
subsistence activity – SKIP to question 35a

How many minutes did it usually take you to
get from this address to work LAST WEEK?
Minutes

30. At what location did you work LAST WEEK?
Answer questions 35–38 if you did NOT work last week.
Do not include subsistence activity. If you worked at
Otherwise, SKIP to question 39.
more than one location, print where you worked most
last week.
35a. LAST WEEK, were you on layoff from a job?
a. What is the name of the island, U.S. state,
Yes – SKIP to question 35c
commonwealth, territory, or foreign country?
No

b. What is the name of the city, town, or village?

31. How did you usually get to work LAST
WEEK? Do not include transportation to
subsistence activity. If you usually used more than
one method of transportation during the trip, mark ✗
the box of the one used for most of the distance.
Car, truck, or private van/bus
Public van/bus
Boat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home – SKIP to question 39
Other method

b. LAST WEEK, were you TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness, maternity
leave, other family/personal reasons, bad weather,
etc. – SKIP to question 38
No – SKIP to question 36

c. Have you been informed that you will be
recalled to work within the next 6 months
OR been given a date to return to work?
Yes – SKIP to question 37
No

36.

During the LAST 4 WEEKS, have you been
ACTIVELY looking for work?
Yes
No – SKIP to question 38

37.

LAST WEEK, could you have started a job if
offered one, or returned to work if recalled?
Yes, could have gone to work
No, because of own temporary illness
No, because of all other reasons (in school, etc.)

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38. When did you last work, even for a few
days? Do not include subsistence activity.
2010
2009
2008
2005 to 2007
2000 to 2004 – SKIP to question 48
1999 or earlier – SKIP to question 48
Never worked; or did subsistence only – SKIP to
question 48

41. What kind of business or industry was
this? Describe the activity at the location where
employed. (For example: hospital, fish cannery,
watchmaker, auto repair shop, bank)

39–44.

42. Is this mainly – Mark ✗ ONE box.
Manufacturing?
Wholesale trade?
Retail trade?
Other (agriculture, construction, service,
government, etc.)?

CURRENT OR MOST RECENT JOB
ACTIVITY

Describe clearly your chief job activity or
business last week. If you had more than one
job, describe the one at which you worked the
most hours. If you had no job or business last
week, give information for your last job or
business since 2005.
39. Were you – Mark ✗ ONE box.

43. What kind of work were you doing? (For
example: registered nurse, machine repairer,
watchmaker, secretary, accountant)

An employee of a PRIVATE FOR-PROFIT
company or business or of an individual, for
wages, salary, or commissions?
An employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?
A local or territorial GOVERNMENT employee
(territorial/commonwealth, etc.) ?
A federal GOVERNMENT employee?
SELF-EMPLOYED in own NOT
INCORPORATED business, professional
practice, or farm?
SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
Working WITHOUT PAY in family business or
farm?

40. For whom did you work?
If now on active duty in the Armed Forces,
mark ✗ this box
and print the branch of the Armed Forces.
Name of company, business, or other
employer

44. What were your most important activities
or duties? (For example: patient care, repairing
machinery, making watches, typing and filing,
reconciling financial records)

45. LAST YEAR, 2009, did you work at a job
or business at any time? Do not include
subsistence activity.
Yes
No – SKIP to question 48

46a. During 2009 (all 52 weeks), did you work
50 or more weeks? Count paid time off as
work. Do not include subsistence activity.
Yes – SKIP to question 47
No

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46b. How many weeks DID you work, even for
a few hours, including paid vacation, paid
sick leave, and military service? Do not
include subsistence activity.
50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

47.

48.

INCOME IN 2009
Mark ✗ the "Yes" box for each income source
received during 2009, and enter the total amount
received during 2009 to a maximum of $999,999
($99,999 for questions 48d and 48e). Mark ✗ the
"No" box if the income source was not received.
If net income was a loss, enter the amount and
mark ✗ the "Loss" box next to the dollar amount.

a. Wages, salary, commissions, bonuses, or
tips from all jobs. Report amount before
deductions for taxes, bonds, dues, or other items.
Annual amount – Dollars

$

,

.00

b. Self-employment income from own
nonfarm businesses or farm businesses,
including proprietorships and partnerships.
Report NET income after business expenses.
Annual amount – Dollars
Yes
No

$

,

Loss

.00

c. Interest, dividends, net rental income,
royalty income, or income from estates
and trusts. Report even small amounts credited
to an account.
Annual amount – Dollars
Yes
No

$

Annual amount – Dollars
Yes
No

$

,

.00

e. Any public assistance or welfare payments
from the state or local welfare office,
including Supplemental Security Income
(SSI).
Annual amount – Dollars

During 2009, in the WEEKS WORKED, how
many hours did you usually work each
WEEK? Do not include subsistence activity.
Usual hours worked each WEEK

Yes
No

48d. Social Security or Railroad Retirement.

,

.00

Yes
No

$

,

.00

f. Retirement, survivor, or disability pensions.
Do NOT include Social Security.
Annual amount – Dollars
Yes
No

$

,

.00

g. Any remittances. Include money from relatives
outside the household or in the military.
Annual amount – Dollars
Yes
No

$

,

.00

h. Any other sources of income received
regularly such as Veterans’ (VA) payments,
unemployment compensation, child support,
or alimony. Do NOT include lump-sum payments
such as money from an inheritance or sale of a home.
Annual amount – Dollars
Yes
No

$

,

.00

49. What was your total income during 2009?
Add entries in questions 48a–48h; subtract any
losses. If net income was a loss, enter the amount and
mark ✗ the "Loss" box next to the dollar amount.
Annual amount – Dollars
Loss
None OR

$

,

.00

50. During 2009, did you GIVE or SEND money
TO relatives or friends living outside of this
area? Do not include charitable contributions or
Loss
money given to charitable organizations. If exact
amount is not known, please give best estimate.
Yes
No

$

,

.00

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51. Please check this form to be sure you have
answered all the required questions
completely.
To return your form, please follow the
instructions on the envelope that the form
came in.

Thank you for
completing this official
Census 2010 form.
The Census Bureau estimates that, on average, each
respondent will take 24 minutes to complete this form,
including the time for reviewing the instructions and
answers. Send comments regarding this burden
estimate or any aspect of the burden to: Paperwork
Reduction Project 0607-0000, U.S. Census Bureau,
4600 Silver Hill Road, AMSD-3K138, Washington, DC
20233. You may email comments to
Paperwork@census.gov; use "Paperwork Project
0607-0000" 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.

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FOR OFFICE USE ONLY

FOROFFICE
OFFICE USE
ONLY
FOR
USE
ONLY
A. GQ ID

B. LCO

H. Add

C. County

I. GQ Type

D. Block

E. AA

F. Map Spot

G. PN

J. JIC

Y N

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