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Attachment X: ACS Respondent Burden Testing Paper Survey Instrument: Group 3, Version 1
DC
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
THE
American Community Survey
Start Here
Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it
back as soon as possible.
➜
Please print today’s date.
Month
Day
Year
➜
Please print the name and telephone number of the person who is
filling out this form. We may contact you if there is a question.
Last Name
This form asks for information about the
people who are living or staying at the
address on the mailing label and about the
house, apartment, or mobile home located
at the address on the mailing label.
MI
First Name
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.
● INCLUDE yourself if you are living here for more than 2 months.
● INCLUDE anyone else staying here who does not have another place to
stay, even if they are here for 2 months or less.
● DO NOT INCLUDE anyone who is living somewhere else for more than
2 months, such as a college student living away or someone in the
Armed Forces on deployment.
Number of people
➜
Fill out pages 2, 3, and 4 for everyone, including yourself, who is
living or staying at this address for more than 2 months. Then
complete the rest of the form.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. The telephone call is free.
¿NECESITA AYUDA? Si usted habla español y
necesita ayuda para completar su cuestionario,
llame sin cargo alguno al 1-877-833-5625.
Usted también puede completar su entrevista
por teléfono con un entrevistador que habla
español. O puede responder por Internet en:
https://respond.census.gov/acs
For more information about the American
Community Survey, visit our web site at:
http://www.census.gov/acs/www/
ACS-1(X)G3V2
FORM
(03-24-2016) Draft 1
§.#]3¤
OMB No. 0607-0810
OMB No. 0607-0936
13026026
Person 1
Person 2
1 What is Person 2’s name?
(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.)
Last Name (Please print)
First Name
MI
2 How is this person related to Person 1? Mark (X) ONE box.
1
What is Person 1’s name?
Last Name (Please print)
2
First Name
MI
How is this person related to Person 1?
X
3
Person 1
4
Female
Month
Day
Year of birth
Question 6 about race. For this survey, Hispanic origins are not races.
6
Is Person 1 of Hispanic, Latino, or Spanish origin?
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Female
4 What is Person 2’s age and what is Person 2’s date of birth?
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
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 2 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,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
What is Person 1’s race? Mark (X) one or more boxes.
6 What is Person 2’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
2
Adopted son or daughter
Male
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
5
Other relative
3 What is Person 2’s sex? Mark (X) ONE box.
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.
Print numbers in boxes.
Age (in years)
Son-in-law or daughter-in-law
Biological son or daughter
Parent-in-law
What is Person 1’s sex? Mark (X) ONE box.
Male
Husband or wife
§.#];¤
Some other race – Print race. C
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
13026034
Person 3
1
1 What is Person 4’s name?
What is Person 3’s name?
Last Name (Please print)
2
Person 4
First Name
MI
How is this person related to Person 1? Mark (X) ONE box.
Husband or wife
Son-in-law or daughter-in-law
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
3 What is Person 4’s sex? Mark (X) ONE box.
What is Person 3’s sex? Mark (X) ONE box.
Female
Male
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.
Print numbers in boxes.
Month
Day
Year of birth
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
6
2 How is this person related to Person 1? Mark (X) ONE box.
Son-in-law or daughter-in-law
Age (in years)
5
MI
Biological son or daughter
Male
4
First Name
Husband or wife
Parent-in-law
3
Last Name (Please print)
Is Person 3 of Hispanic, Latino, or Spanish origin?
Female
4 What is Person 4’s age and what is Person 4’s date of birth?
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
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this survey, Hispanic origins are not races.
5 Is Person 4 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,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
What is Person 3’s race? Mark (X) one or more boxes.
6 What is Person 4’s race? Mark (X) one or more boxes.
White
White
Black or African Am.
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Asian Indian
Japanese
Native Hawaiian
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Filipino
Vietnamese
Samoan
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Some other race – Print race. C
§.#]C¤
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Some other race – Print race. C
3
13026042
Person 5
1
➜
What is Person 5’s name?
Last Name (Please print)
First Name
MI
If there are more than five people living or staying here,
print their names in the spaces for Person 6 through Person 12.
We may call you for more information about them.
Person 6
Last Name (Please print)
2
First Name
MI
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
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
Sex
Male
Female
Age (in years)
Person 7
Last Name (Please print)
First Name
MI
Parent-in-law
3
What is Person 5’s sex? Mark (X) ONE box.
Male
4
Sex
Female
Female
Age (in years)
Person 8
What is Person 5’s age and what is Person 5’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age (in years)
Male
Month
Day
Last Name (Please print)
First Name
MI
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.
5
Is Person 5 of Hispanic, Latino, or Spanish origin?
Person 9
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
Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard,
and so on. C
Male
Female
Person 10
Last Name (Please print)
6
Age (in years)
First Name
MI
What is Person 5’s race? Mark (X) one or more boxes.
White
Sex
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C
Male
Female
Person 11
Last Name (Please print)
Asian Indian
Japanese
Native Hawaiian
Chinese
Korean
Guamanian or Chamorro
Filipino
Vietnamese
Samoan
Other Asian – Print race,
for example, Hmong,
Laotian, Thai, Pakistani,
Cambodian, and so on. C
Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C
Age (in years)
Sex
Male
First Name
Female
Age (in years)
Person 12
Last Name (Please print)
First Name
Some other race – Print race. C
Sex
4
§.#]K¤
MI
Male
Female
Age (in years)
MI
13026059
Person 1
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
14 a. Does this person speak a language other than
English at home?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
Yes
No ➔ SKIP to question 15a
b. What is this language?
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
c. How well does this person speak English?
GED or alternative credential
Very well
COLLEGE OR SOME COLLEGE
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Well
Some college credit, but less than 1 year of
college credit
Yes, born abroad of U.S. citizen parent
or parents
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Not well
Not at all
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to page 7
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Yes, this house
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Address (Number and street name)
12 This question focuses on this person’s
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
No, different house in the United States or
Puerto Rico
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
City
Nursery school, preschool
Kindergarten
State
ZIP
Grade 1 through 12 – Specify
grade 1 – 12
County
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)
§.#]\¤
5
13026067
Person 1 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address (Number and street name)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. City
38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to next page
Over 5 years ago or never worked ➔ SKIP to
next page
39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?
K
c. State or foreign country
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
d. ZIP
40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
e. County
No
f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
6
Usual hours worked each WEEK
§.#]d¤
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks
13026075
Person 2
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 2 from page 2,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
14 a. Does this person speak a language other than
English at home?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
Yes
No ➔ SKIP to question 15a
b. What is this language?
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
c. How well does this person speak English?
GED or alternative credential
Very well
COLLEGE OR SOME COLLEGE
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Well
Some college credit, but less than 1 year of
college credit
Yes, born abroad of U.S. citizen parent
or parents
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Not well
Not at all
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to page 9
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Yes, this house ➔ SKIP to next page
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Address (Number and street name)
12 This question focuses on this person’s
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
No, different house in the United States or
Puerto Rico
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
City
Nursery school, preschool
Kindergarten
State
ZIP
Grade 1 through 12 – Specify
grade 1 – 12
County
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)
§.#]l¤
7
13026083
Person 2 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address (Number and street name)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. City
38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to next page
Over 5 years ago or never worked ➔ SKIP to
next page
39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?
K
c. State or foreign country
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
d. ZIP
40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
e. County
No
f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
8
Usual hours worked each WEEK
§.#]t¤
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks
13026091
Person 3
11 What is the highest degree or level of school
this person has COMPLETED? Mark (X) ONE box.
➜
If currently enrolled, mark the previous grade or
highest degree received.
Please copy the name of Person 3 from page 3,
then continue answering questions below.
Last Name
NO SCHOOLING COMPLETED
No schooling completed
First Name
NURSERY OR PRESCHOOL THROUGH GRADE 12
MI
Nursery school
Kindergarten
7
13 What is this person’s ancestry or ethnic origin?
Where was this person born?
(For example: Italian, Jamaican, African Am.,
Cambodian, Cape Verdean, Norwegian, Dominican,
French Canadian, Haitian, Korean, Lebanese, Polish,
Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
14 a. Does this person speak a language other than
English at home?
Grade 1 through 11 – Specify
grade 1 – 11
In the United States – Print name of state.
Yes
No ➔ SKIP to question 15a
b. What is this language?
Outside the United States – Print name of
foreign country, or Puerto Rico, Guam, etc.
12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
Regular high school diploma
8
Is this person a citizen of the United States?
Yes, born in the United States ➔ SKIP to
question 10a
c. How well does this person speak English?
GED or alternative credential
Very well
COLLEGE OR SOME COLLEGE
Yes, born in Puerto Rico, Guam, the
U.S. Virgin Islands, or Northern Marianas
Well
Some college credit, but less than 1 year of
college credit
Yes, born abroad of U.S. citizen parent
or parents
1 or more years of college credit, no degree
Yes, U.S. citizen by naturalization – Print year
of naturalization
Associate’s degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
AFTER BACHELOR’S DEGREE
No, not a U.S. citizen
9
For example: Korean, Italian, Spanish, Vietnamese
Not well
Not at all
15 a. Did this person live in this house or apartment
1 year ago?
Person is under 1 year old ➔ SKIP to page 11
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)
When did this person come to live in the
United States? If this person came to live in the
United States more than once, print latest year.
Year
Yes, this house ➔ SKIP to next page
No, outside the United States and
Puerto Rico – Print name of foreign country,
or U.S. Virgin Islands, Guam, etc., below;
then SKIP to next page
Doctorate degree (for example: PhD, EdD)
10 a. At any time IN THE LAST 3 MONTHS, has
this person attended school or college?
F
Include only nursery or preschool, kindergarten,
elementary school, home school, and schooling
which leads to a high school diploma or a college
degree.
Answer question 12 if this person has a
bachelor’s degree or higher. Otherwise,
SKIP to question 13.
b. Where did this person live 1 year ago?
No, has not attended in the last 3
months ➔ SKIP to question 11
Yes, public school, public college
Address (Number and street name)
12 This question focuses on this person’s
Yes, private school, private college,
home school
b. What grade or level was this person attending?
Mark (X) ONE box.
No, different house in the United States or
Puerto Rico
BACHELOR’S DEGREE. Please print below the
specific major(s) of any BACHELOR’S DEGREES
this person has received. (For example: chemical
engineering, elementary teacher education,
organizational psychology)
City
Nursery school, preschool
Kindergarten
State
ZIP
Grade 1 through 12 – Specify
grade 1 – 12
County
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)
§.#]|¤
9
13026109
Person 3 (continued)
J
29 a. LAST WEEK, did this person work for pay
Answer question 32 if you marked "Car,
truck, or van" in question 31. Otherwise,
SKIP to question 33.
at a job (or business)?
36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38
Yes ➔ SKIP to question 30
No – Did not work (or retired)
32 How many people, including this person,
usually rode to work in the car, truck, or van
LAST WEEK?
b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?
Person(s)
37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes
Yes, could have gone to work
No ➔ SKIP to question 35a
No, because of own temporary illness
30 At what location did this person work LAST
33 What time did this person usually leave home
WEEK? If this person worked at more than one
location, print where he or she worked most
last week.
Hour
Minute
:
a. Address (Number and street name)
If the exact address is not known, give a
description of the location such as the building
name or the nearest street or intersection.
No, because of all other reasons (in school, etc.)
to go to work LAST WEEK?
a.m.
p.m.
34 How many minutes did it usually take this
person to get from home to work LAST WEEK?
Minutes
b. City
38 When did this person last work, even for a few
days?
Within the past 12 months
1 to 5 years ago ➔ SKIP to next page
Over 5 years ago or never worked ➔ SKIP to
next page
39 Over the past 52 weeks, that is since one year
ago today, in the WEEKS WORKED, how many
hours did this person usually work each WEEK?
K
c. State or foreign country
Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.
d. ZIP
40 a. Over the past 52 weeks, that is since one year
35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
e. County
No
f. Is the work location inside the limits of that
city or town?
Yes
No, outside the city/town limits
b. LAST WEEK, was this person TEMPORARILY
absent from a job or business?
Yes, on vacation, temporary illness,
maternity leave, other family/personal
reasons, bad weather, etc. ➔ SKIP to
question 38
No ➔ SKIP to question 36
31 How did this person usually get to work LAST
WEEK? If this person usually used more than one
method of transportation during the trip, mark (X)
the box of the one used for most of the distance.
Car, truck, or van
Motorcycle
Bus or trolley bus
Bicycle
Streetcar or trolley car
Walked
Subway or elevated
Railroad
Worked at
home ➔ SKIP
to question 39
Ferryboat
Other method
Taxicab
10
Usual hours worked each WEEK
§.#^*¤
c. Has this person been informed that he or she
will be recalled to work within the next
6 months OR been given a date to return to
work?
Yes ➔ SKIP to question 37
No
ago today, did this person work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to next page
No
b. Over the past 52 weeks, that is since one year
ago today, how many WEEKS did this person
work? Include paid time off and include weeks
when this person only worked for a few hours.
Weeks
13026117
Mailing
Instructions
➜ Please make sure you have...
• listed all names and answered the questions on
pages 2, 3, and 4
• 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.
For Census Bureau Use
POP
EDIT
EDIT CLERK
PHONE
TELEPHONE CLERK
JIC1
JIC2
JIC3
JIC4
The Census Bureau estimates that, for the average
household, this form will take 40 minutes to complete,
including the time for reviewing the instructions and
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 and 0607-0936,
U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138,
Washington, D.C. 20233. You may e-mail comments to
AMSD.Paperwork@census.gov; use "Paperwork Project
0607-0810 and 0607-0936" as the subject. Please
DO NOT RETURN your questionnaire to this address.
Use the enclosed 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(X)G3V2 (03-24-2016)
§.#^2¤
11
File Type | application/pdf |
File Modified | 2016-04-25 |
File Created | 2016-03-24 |