Form Paper Survey Quest Paper Survey Quest Paper Survey Questions

Generic Clearance for Questionnaire Pretesting Research

Attachment G_Paper Survey Questions

2017 American Community Survey Respondent Burden Testing

OMB: 0607-0725

Document [pdf]
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13027016

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 will only contact you if needed for official
Census Bureau business.
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.
Telephone Device for the Deaf (TDD):
Call 1–800–582–8330. 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.

¿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

ACS-1(X)IWW

FORM
(10-06-2016) Draft 3

§.#g1¤

OMB No. 0607-0810
OMB No. 0607-0936

13027024

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

§.#g9¤

Some other race – Print race. C

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C

13027032

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

§.#gA¤

Other Pacific Islander –
Print race, for example,
Fijian, Tongan, and
so on. C

Some other race – Print race. C

3

13027040

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

§.#gI¤

MI

Male

Female

Age (in years)

MI

13027107

Person 1
➜

J

Please copy the name of Person 1 from page 2,
then continue answering questions below.
Last Name

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

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

32 How many people, including this person,
First Name

usually rode to work in the car, truck, or van
LAST WEEK?

MI

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work

30 a. LAST WEEK, did this person work for pay

No, because of own temporary illness

at a job (or business)?

33 What time did this person usually leave home

Yes ➔ SKIP to question 31

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

No – Did not work (or retired)

Hour

Minute

:

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

a.m.
p.m.

Yes

34 How many minutes did it usually take this

No ➔ SKIP to question 35a

person to get from home to work LAST WEEK?
Minutes

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one

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

days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47

39 During the 52 weeks covering 2015, that is from

method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

38 When did this person last work, even for a few

January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No

Usual hours worked each WEEK

40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No

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
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

10

§.#h(¤

b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks

13027115

Person 1 (continued)
L

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

45 What kind of work was this person doing?

f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.

46 What were this person’s most important

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.

41 Was this person –
Mark (X) ONE box.

47 INCOME RECEIVED IN 2015

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Consider income received from January 1, 2015 to
December 31, 2015.

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?

a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?

a Federal GOVERNMENT employee?

Yes

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Yes
No

48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.

b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.

If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.

Yes
For income received jointly, include the appropriate
share for this person in the total.

No
Loss

If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.

c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.

OR
None

$

,

,

TOTAL AMOUNT for 2015

.00
Loss

Yes
No
Loss

44 Is this mainly – Mark (X) ONE box.
manufacturing?

d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No

wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No

§.#h0¤

➜

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.

11

13027149

Person 2
➜

J

Please copy the name of Person 2 from page
2,then continue answering questions below.
Last Name

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

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

32 How many people, including this person,
First Name

usually rode to work in the car, truck, or van
LAST WEEK?

MI

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work

30 a. LAST WEEK, did this person work for pay

No, because of own temporary illness

at a job (or business)?

33 What time did this person usually leave home

Yes ➔ SKIP to question 31

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

No – Did not work (or retired)

Hour

Minute

:

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

a.m.
p.m.

Yes

34 How many minutes did it usually take this

No ➔ SKIP to question 35a

person to get from home to work LAST WEEK?
Minutes

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one

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

days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47

39 During the 52 weeks covering 2015, that is from

method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

38 When did this person last work, even for a few

January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No

Usual hours worked each WEEK

40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No

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
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

14

§.#hR¤

b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks

13027156

Person 2 (continued)
L

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

45 What kind of work was this person doing?

f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.

46 What were this person’s most important

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.

41 Was this person –
Mark (X) ONE box.

47 INCOME RECEIVED IN 2015

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Consider income received from January 1, 2015 to
December 31, 2015.

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?

a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?

a Federal GOVERNMENT employee?

Yes

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Yes
No

48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.

b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.

If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.

Yes
For income received jointly, include the appropriate
share for this person in the total.

No
Loss

If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.

c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.

OR
None

$

,

,

TOTAL AMOUNT for 2015

.00
Loss

Yes
No
Loss

44 Is this mainly – Mark (X) ONE box.
manufacturing?

d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No

wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No

§.#hY¤

➜

Continue with the questions for Person 3 on
the next page. If no one is listed as Person 3 on
page 3, SKIP to page 28 for mailing instructions.

15

13027180

Person 3
➜

J

Please copy the name of Person 3 from page
3,then continue answering questions below.
Last Name

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

36 During the LAST 4 WEEKS, has this person been
ACTIVELY looking for work?
Yes
No ➔ SKIP to question 38

32 How many people, including this person,
First Name

usually rode to work in the car, truck, or van
LAST WEEK?

MI

Person(s)

37 LAST WEEK, could this person have started a
job if offered one, or returned to work if
recalled?
Yes, could have gone to work

30 a. LAST WEEK, did this person work for pay

No, because of own temporary illness

at a job (or business)?

33 What time did this person usually leave home

Yes ➔ SKIP to question 31

No, because of all other reasons (in school, etc.)

to go to work LAST WEEK?

No – Did not work (or retired)

Hour

Minute

:

b. LAST WEEK, did this person do ANY work
for pay, even for as little as one hour?

a.m.
p.m.

Yes

34 How many minutes did it usually take this

No ➔ SKIP to question 35a

person to get from home to work LAST WEEK?
Minutes

31 How did this person usually get to work LAST
WEEK? If this person usually used more than one

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

days?
Within the past 12 months
1 to 5 years ago
Over 5 years ago or never worked ➔ SKIP to
question 47

39 During the 52 weeks covering 2015, that is from

method of transportation during the trip, mark (X)
the box of the one used for most of the distance.

Car, truck, or van

38 When did this person last work, even for a few

January 1, 2015 to December 31,2015, in the
WEEKS WORKED, how many hours did this
person usually work each WEEK?

K

Answer questions 35 – 38 if this person
did NOT work last week. Otherwise,
SKIP to question 39.

35 a. LAST WEEK, was this person on layoff from
a job?
Yes ➔ SKIP to question 35c
No

Usual hours worked each WEEK

40 a. During the 52 weeks covering 2015, did
this person work EVERY week? Count
paid vacation, paid sick leave, and
military service as work.
Yes ➔ SKIP to question 41
No

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
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

18

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b. During the 52 weeks covering 2015, how
many WEEKS did this person work? Include
paid time off and include weeks when this
person only worked for a few hours.
Weeks

13027198

Person 3 (continued)
L

Answer questions 41 – 46 if this person
worked in the past 5 years. Otherwise,
SKIP to question 47.

41 – 46 CURRENT OR MOST RECENT JOB
ACTIVITY. Describe clearly this person’s chief
job activity or business last week. If this person
had more than one job, describe the one at
which this person worked the most hours. If this
person had no job or business last week, give
information for his/her last job or business.

45 What kind of work was this person doing?

f. In 2015, did this person receive any public
assistance or welfare payments from the state
or local welfare office?

(For example: registered nurse, personnel manager,
supervisor of order department, secretary,
accountant)

Yes
No
g. In 2015, did this person receive retirement,
survivor, or disability pensions? This does NOT
include Social Security.

46 What were this person’s most important

activities or duties? (For example: patient care,
directing hiring policies, supervising order clerks,
typing and filing, reconciling financial records)

Yes
No
h. In 2015, did this person receive any other
sources of income regularly such as Veterans’
(VA) payments, unemployment, compensation,
child support or alimony? This does NOT include
lump sum payments such as money from an
inheritance or the sale of a home.

41 Was this person –
Mark (X) ONE box.

47 INCOME RECEIVED IN 2015

an employee of a PRIVATE FOR-PROFIT
company or business, or of an individual, for
wages, salary, or commissions?

Consider income received from January 1, 2015 to
December 31, 2015.

an employee of a PRIVATE NOT-FOR-PROFIT,
tax-exempt, or charitable organization?

For income received jointly, if you know the
appropriate amount for each person, mark (X) “Yes”
for each person. If not, mark (X) “Yes” for only one
person and mark (X) “No” for the other person.

a local GOVERNMENT employee
(city, county, etc.)?
a state GOVERNMENT employee?

a. In 2015, did this person receive wages,
salary, commissions, bonuses, or tips?

a Federal GOVERNMENT employee?

Yes

SELF-EMPLOYED in own NOT INCORPORATED
business, professional practice, or farm?

No

SELF-EMPLOYED in own INCORPORATED
business, professional practice, or farm?
working WITHOUT PAY in family business
or farm?

42 For whom did this person work?
If now on active duty in
the Armed Forces, mark (X) this box ➔
and print the branch of the Armed Forces.
Name of company, business, or other employer

43 What kind of business or industry was this?

Describe the activity at the location where employed.
(For example: hospital, newspaper publishing, mail
order house, auto engine manufacturing, bank)

Yes
No

48 What was this person’s total income in 2015
from all sources?
Include income amounts for questions 47a to 47h
that were marked (X) "Yes."
If "Yes" for 47a, include amount from all jobs before
deductions for taxes, bonds, dues, or other items.

b. In 2015, did this person receive selfemployment income from own nonfarm
businesses or farm businesses, including
proprietorships and partnerships? If the net
income was a loss, mark (X) the "Loss" box.

If "Yes" for 47b, include NET income after business
expenses.
If "Loss" for 47b or 47c, subtract amount from total
income.

Yes
For income received jointly, include the appropriate
share for this person in the total.

No
Loss

If net income was a loss, enter the amount and mark
(X) the "Loss" box next to the dollar amount.

c. In 2015, did this person receive interest,
dividends, net rental income, royalty
income, or income from estates and trusts?
Consider even small amounts credited to an
account. If the net income was a loss, mark (X)
the "Loss" box.

OR
None

$

,

,

TOTAL AMOUNT for 2015

.00
Loss

Yes
No
Loss

44 Is this mainly – Mark (X) ONE box.
manufacturing?

d. In 2015, did this person receive Social Security
or Railroad Retirement?
Yes
No

wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?

e. In 2015, did this person receive Supplemental
Security Income (SSI)?
Yes
No

§.#h¥¤

➜

Now continue with the mailing instructions on
page 28.

19

13197280

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.

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)IWW (10-06-2016)

28

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File Modified2016-10-18
File Created2016-10-06

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