Island Areas Censuses - Housing Units

2020 Census

Island Areas Censuses Housing Materials

Island Areas Censuses - Housing Units

OMB: 0607-1006

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-1006 can be found here:

2021-11-10 - No material or nonsubstantive change to a currently approved collection
2020-07-02 - No material or nonsubstantive change to a currently approved collection

Document [pdf]

Download: pdf | pdf

FORM

D-ARCP-AS (11-7-2018)

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

This listing contains conﬁdential information, including Title 13 and Personally Identiﬁable Information (PII), the release of which is protected by the Privacy Act of 1974.

1. IDENTIFICATION

HOUSING UNIT ADDRESS REGISTER
2020 Census of American Samoa

County
BCU
Book

2. ASSIGNMENT INFORMATION
Name – Please Print

Employee ID
Number

Telephone Number

Certiﬁcation Statement – I certify that the information is
true to the best of my knowledge and the work completed
according to Census Bureau procedures.

Date
Completed

Assigned

Enumerator
Reassigned Enumerator
Reassigned Enumerator

Crew Leader

The Crew Leader and all Enumerators must sign this
certification statement.

Date
Number

Housing Units
Listed

3. ENUMERATOR DAILY PROGRESS RECORD (LISTING)

4. ENUMERATOR DAILY PROGRESS RECORD (ENUMERATION)

Housing Units
Enumerated

Date
Number

Remarks

5. OFFICE USE ONLY
Name of Reviewer

Date

Initials

The contents of this Address Register are conﬁdential by law (Title 13, U.S.
Code). It may be seen only by sworn persons with a need to know and used
solely for statistical purposes.

CREW LEADER REVIEW CHECKLIST

Before sending to the Census Ofﬁce, verify the following:
The Enumerator has made entries in a legible manner.
All appropriate fields are completed in the Address Listing Page for Housing Units.
There are no duplicate addresses listed in the Address Listing Page for Housing Units.
There is an entry of 0 in Pop. Count for vacant units in the Address Listing Page for Housing Units.

The Enumerator completed the Assignment Information section.

SPECIAL NOTICE

INFORMATION CONTAINED IN THIS ADDRESS REGISTER IS CONFIDENTIAL.
ALL ENTRIES MADE IN THIS ADDRESS REGISTER MUST BE LEGIBLE,
COMPLETE, AND ACCURATE.

FORM D-ARCP-AS (11-7-2018)

FORM

D-ARCP-TL-AS (11-7-2018)

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

This listing contains conﬁdential information, including Title 13 and Personally Identiﬁable Information (PII), the release of which is protected by the Privacy Act of 1974.

1. IDENTIFICATION

TRANSITORY LOCATIONS ADDRESS REGISTER
2020 Census of American Samoa

County
BCU
Book

2. ASSIGNMENT INFORMATION
Name – Please Print

Employee ID
Number

Telephone Number

Certiﬁcation Statement – I certify that the information is true to the best
of my knowledge and the work completed according to Census Bureau
procedures.

Date
Completed

The Crew Leader and all Enumerators must sign this certification statement.

Assigned
Crew Leader

Reassigned Enumerator
Reassigned Enumerator

Enumerator

Transitory Units
Listed

Date
Number

3. ENUMERATOR DAILY PROGRESS RECORD (LISTING)

Transitory Units
Enumerated

Date
Number

4. ENUMERATOR DAILY PROGRESS RECORD (ENUMERATION)

Remarks

5. OFFICE USE ONLY
Name of Reviewer

Date

Initials

The contents of this Address Register are conﬁdential by law (Title 13, U.S.
Code). It may be seen only by sworn persons with a need to know and used
solely for statistical purposes.

CREW LEADER REVIEW CHECKLIST

Before sending to the Census Ofﬁce, verify the following:
The Enumerator has made entries in a legible manner.
All appropriate fields are completed in the Address Listing Page for Transitory Locations and Address Listing Page for Transitory Units.
There are no duplicate addresses listed in the Address Listing Page for Transitory Locations and Address Listing Page for Transitory Units.
There is an entry of 0 in Pop. Count for vacant units in the Address Listing Page for Transitory Locations and Address Listing Page for Transitory Units.

The Enumerator completed the Assignment Information section.

SPECIAL NOTICE

INFORMATION CONTAINED IN THIS ADDRESS REGISTER IS CONFIDENTIAL.
ALL ENTRIES MADE IN THIS ADDRESS REGISTER MUST BE LEGIBLE,
COMPLETE, AND ACCURATE.

FORM D-ARCP-TL-AS (11-7-2018)

FORM

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-ARLP-AS (11-7-2018)

ADDRESS LISTING PAGE FOR HOUSING UNITS
2020 Census of American Samoa
County
Questionnaire ID

Date
Listed

Map Spot No.
(4)
MUID

(1)
(1)

(3)

(2)
(2)

(3)

➤

APPLY LABEL HERE

(5)
(4)

(6)

(2)

(3)

➤

(4)

(6)

(18) Mailable?
(Y/N/DK)

➤

(18) Mailable?
(Y/N/DK)

➤
➤

(16) Case Status – Enumeration

O – Other

GQ – Group Quarters
TL – Transitory Locations
NLQ – Non-Living Quarters

ZIP Code

Estate – U.S. Virgin Islands Only

(8)

(10)

(12)

(14)

(7)

(9)

(11)

(13)

(8)

(10)

(12)

(14)

(21) Contact
Attempts –
FFU (Tally)

(22) Pop. Count

(4)

(6)

(17) Contact Attempts –
Enumeration (Tally)

(18) Mailable?
(Y/N/DK)

Remarks

(15)
(15)

(11)

(13)

(8)

(10)

(12)

(14)

(21) Contact
Attempts –
FFU (Tally)

(22) Pop. Count

CI – Conducted Interview
GC – Gated Community
LB – Language Barrier
NC – No Contact

NV – Left Notice of Visit
RA – Restricted Access
RE – Refusal
UN – Unsafe
OT – Other

(20) Case Status – FFU

(9)

(11)

(13)

(8)

(10)

(12)

(14)

(21) Contact
Attempts –
FFU (Tally)

(22) Pop. Count

Abbreviations
Apt – Apartment
BCU – Basic Collection Unit
FFU – Field Followup
MUID – Multi-Unit Identification

(25) JIC2

(15)

(23) QC Action
(25) JIC2

(24) JIC1

(7)

(20) Case Status – FFU

(23) QC Action
(24) JIC1

(9)

(19) Date Enumerated

Case Status Codes
A – Appointment

(20) Case Status – FFU

(7)

(19) Date Enumerated

(5)

S – Single Unit
M – Multi-Unit
T – Trailer/Mobile Home

Physical Location Description

(19) Date Enumerated

(17) Contact Attempts –
Enumeration (Tally)

(3)

Address Type Codes

Address Type

(5)

(2)

APPLY LABEL HERE

Village OR
(13)

(17) Contact Attempts –
Enumeration (Tally)

(16) Case Status – Enumeration

(1)

Apt/Unit No.
(11)

➤

(16) Case Status – Enumeration

APPLY LABEL HERE

Complete Street Name OR
(9)

(6)

(5)

(1)

Address No.
(7)

Development/Building Name OR
Subdivision/Place Name

Line
No.

BCU

(15)

(23) QC Action
(25) JIC2

(24) JIC1

Additional Remarks

Page Totals

No. – Number
Pop. – Population
QC – Quality Control
Y/N/DK – Yes, No, Don’t Know

Occupied
HUs

Vacant
HUs

GQs

TLs

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

FORM D-ARLP-TL-AS (11-13-2018)

ADDRESS LISTING PAGE FOR TRANSITORY LOCATIONS
2020 Census of American Samoa

BCU

County
Date Assigned

Transitory Location ID

Map Spot
No.

Address No.

Complete Street Name
OR

Apt/Unit/Slip
No.

Village OR

Transitory Location Point of
Contact Name

(3)

(6)

(8)

(10)

(12)

(14)

MUID

TL Type

ZIP Code

Estate –
U.S. Virgin Islands Only

Title

Telephone
Number

(11)

(13)

(15)

(16)

(4)

(2)

(1)
(1)

(2)

Transitory Location
Name

(5)

(3)

(5)

10 – Campground
20 – Recreational Vehicle Park
30 – Marina
40 – Hotel and Motel

50 – Racetrack
60 – Circus or Carnival
90 – Other Transitory Locations

Case Status Codes
A – Appointment
EC – Enumeration Complete
GC – Gated Community
LB – Language Barrier
NC – No Contact

NV – Left Notice of Visit
RA – Restricted Access
RE – Refusal
UN – Unsafe
OT – Other

(6)

(8)

(10)

(12)

(14)

(7)

(9)

(11)

(13

(15)

(16)

(26) JIC1

(27) JIC2

(19) Contact Attempts (20) Mailable? (21) Date
– Enumeration
(Y/N/DK)
Enumerated
(Tally)

Abbreviations

Apt – Apartment
BCU – Basic Collection Unit
FFU – Field Followup
MUID – Multi-Unit Identification
No. – Number
Pop. – Population
QC – Quality Control
TL – Transitory Location
TU – Transitory Unit
Y/N/DK – Yes, No, or Don’t Know

TL Type Codes

(9)

(22) Case Status – FFU

(18) Case Status – Enumeration

(17) Establishment Open between
3/29/2020 and 4/16/2020?
(Y/N)

(7)

(4)

Physical Location
Description

Remarks

(23) Contact
(24) Pop.
Attempts –
Count
FFU (Tally)

(25) QC
Action

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-ARLP-TU-AS (11-13-2018)

ADDRESS LISTING PAGE FOR TRANSITORY UNITS
2020 Census of American Samoa
County
Date Listed

(1)

(2)

(3)
(3)

(2)

APPLY LABEL HERE

➤

(15) Case Status – Enumeration

(1)

(3)

➤

(15) Case Status – Enumeration

(1)

(3)

➤

(15) Case Status – Enumeration

Case Status Codes
A – Appointment
CI – Conducted Interview
GC – Gated Community
LB – Language Barrier
NC – No Contact
NV – Left Notice of Visit
RA – Restricted Access
RE – Refusal
UN – Unsafe
OT – Other

MUID
(5)

TL Type
(7)

Physical Location Description
(9)

Abbreviations
Apt – Apartment
BCU – Basic Collection Unit
FFU – Field Followup
MUID – Multi-Unit Identification
No. – Number
Pop. – Population
QC – Quality Control
Y/N/DK – Yes, No, or Don’t Know

Apt/Unit/Slip No.
(10)
ZIP Code
(11)

Estate – U.S. Virgin Islands Only
(13)

(6)

(8)

(10)

(12)

(5)

(7)

(9)

(11)

(13)

(4)

(6)

(5)

(7)

(4)

(18) Date Enumerated

(5)

(19) Case Status – FFU

(8)

(9)

(18) Date Enumerated

(6)

(7)

(16) Contact Attempts – (17) Mailable?
Enumeration (Tally)
(Y/N/DK)

(20) Contact
Attempts –
FFU (Tally)

(10)

(12)

(11)

(13)

(19) Case Status – FFU

(20) Contact
Attempts –
FFU (Tally)

(8)

(10)

(12)

(9)

(11)

(13)

(18) Date Enumerated

(19) Case Status – FFU

(20) Contact
Attempts –
FFU (Tally)

(21) Pop.
Count

BCU
Remarks

Village OR
(12)

(4)

(16) Contact Attempts – (17) Mailable?
Enumeration (Tally)
(Y/N/DK)

(2)

APPLY LABEL HERE

Complete Street Name OR
(8)

(16) Contact Attempts – (17) Mailable?
Enumeration (Tally)
(Y/N/DK)

(2)

APPLY LABEL HERE

Address No.
(6)

(1)

Map Spot No.
(4)

Questionnaire ID

Line
No.

FORM

(14)

(22) QC Action
(23) JIC1

(24) JIC2

(14)

(21) Pop.
Count

(22) QC Action
(23) JIC1

(24) JIC2

(14)

(21) Pop.
Count

(22) QC Action
(23) JIC1

Additional Remarks

(24) JIC2

Page Totals
TUs

HUs

GQs

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

NOTICE OF VISIT

The Census Bureau is conducting the 2020 Census of American
Samoa. An enumerator stopped by today to complete a census
questionnaire for your household, but you were not home. An
enumerator will return to complete your census questionnaire.

(

)–

NOTICE OF VISIT

An enumerator will return on
If you have questions, please call the phone number
below during normal business hours
a.m. to
p.m.).
(Monday through Friday,

R
AF

If you have questions, please call the phone number
below during normal business hours
a.m. to
p.m.).
(Monday through Friday,

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

An enumerator will return on

Phone Number

FORM D-NV-AS

–

Phone Number

(

)–

–

You are required by law to respond to the 2020 Census (Title 13, U.S.
Code, Sections 141 and 193). The Census Bureau estimates that
completing the interview will take 40 minutes on average. This collection of
information has been approved by the Office of Management and Budget
(OMB). The eight-digit OMB approval number xxxx.xxxx confirms this
approval. If this number were not displayed, we could not conduct the
census.

The Census Bureau is required by law to protect your information (Title 13,
U.S. Code, Section 9). The Census Bureau is not permitted to publicly
release your responses in a way that could identify you or your household.
We are conducting the 2020 Cenus under the authority of Title 13, U.S.
Code, Sections 141, 193 and 221. By law, the Census Bureau can only
use your respones to produce statistics. Per the Federal Cybersecurity
Enhancement Act of 2015, your data are protected from cybesecurity risks
through screening of the systems that transmit your data.

For more information about how we protect your information, please visit
our Web site at census.gov and click on "Data Protection and Privacy
Policy" at the bottom of the home page. This page also includes information
about the collection, storage, and use of these records. Click on "System
of Records Notices (SORN)" and look for Privacy Act System of Records
Notice COMMERCE/CENSUS-5, Decennial Census Program.

ENUMERATOR USE ONLY
Case ID

Map Spot No.

ENUMERATOR USE ONLY
Case ID

Map Spot No.

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

NOTICE OF VISIT

The Census Bureau is conducting the 2020 Census of Guam. An
enumerator stopped by today to complete a census questionnaire for
your household, but you were not home. An enumerator will return to
complete your census questionnaire.

(

)–

NOTICE OF VISIT

An enumerator will return on
If you have questions, please call the phone number
below during normal business hours
(Monday through Friday,
a.m. to
p.m.).

R
AF

If you have questions, please call the phone number
below during normal business hours
(Monday through Friday,
a.m. to
p.m.).

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

An enumerator will return on

Phone Number

FORM D-NV-GU

–

Phone Number

(

)–

–

ENUMERATOR USE ONLY
Case ID

Map Spot No.

ENUMERATOR USE ONLY
Case ID

Map Spot No.

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

NOTICE OF VISIT

The Census Bureau is conducting the 2020 Census of the
Commonwealth of the Northern Mariana Islands. An
enumerator stopped by today to complete a census questionnaire for
your household, but you were not home. An enumerator will return to
complete your census questionnaire.

An enumerator will return on

Phone Number

(

)–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

NOTICE OF VISIT

An enumerator will return on

If you have questions, please call the phone number
below during normal business hours
(Monday through Friday,
a.m. to
p.m.).

R
AF

If you have questions, please call the phone number
below during normal business hours
(Monday through Friday,
a.m. to
p.m.).

FORM D-NV-MI

–

Phone Number

(

)–

–

ENUMERATOR USE ONLY
Case ID

Map Spot No.

ENUMERATOR USE ONLY
Case ID

Map Spot No.

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

NOTICE OF VISIT

The Census Bureau is conducting the 2020 Census of the U.S.
Virgin Islands. An enumerator stopped by today to complete a
census questionnaire for your household, but you were not home. An
enumerator will return to complete your census questionnaire.

(

)–

NOTICE OF VISIT

An enumerator will return on
If you have questions, please call the phone number
below during normal business hours
a.m. to
p.m.).
(Monday through Friday,

R
AF

If you have questions, please call the phone number
below during normal business hours
a.m. to
p.m.).
(Monday through Friday,

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

(11-15-2018)

An enumerator will return on

Phone Number

D-NV-VI(E/S)

–

Phone Number

(

)–

–

ENUMERATOR USE ONLY
Case ID

Map Spot No.

ENUMERATOR USE ONLY
Case ID

Map Spot No.

(11-15-2018)

Núm. de OMB xxxx-xxxx: Aprobado hasta xx/xx/xxxx

AVISO DE VISITA

La Oficina del Censo de los EE. UU. está realizando el Censo del 2020
de las Islas Vírgenes de los EE. UU.. Un enumerador pasó por su
casa hoy para completar el cuestionario del censo para su hogar, pero
usted no estaba. Un enumerador regresará para completar su cuestionario
del censo.

Un enumerador regresará el

(11-15-2018)

Núm. de OMB xxxx-xxxx: Aprobado hasta xx/xx/xxxx

AVISO DE VISITA

Un enumerador regresará el

Si usted tiene preguntas, llame al número de teléfono que figura a
continuación durante el horario habitual de atención (de lunes a
a. m. to
p. m.).
viernes, de
Número de teléfono: (
–
)–

R
AF

Si usted tiene preguntas, llame al número de teléfono que figura a
continuación durante el horario habitual de atención (de lunes a
a. m. to
p. m.).
viernes, de
Número de teléfono: (
–
)–

D-NV-VI(E/S)

A usted se le requiere por ley que responda al Censo del 2020 (Secciones 141
y 193 del Título 13 del Código de los EE. UU.). La Oficina del Censo calcula
que completar la entrevista tomará 40 minutos como promedio. Esta
recopilación de información ha sido aprobada por la Oficina de Administración
yPresupuesto (OMB, por sus siglas en inglés). El número de aprobación de
ocho dígitos de la OMB xxxx- xxxx confirma la aprobación. De no mostrarse
este número, no podríamos realizar el censo.

La Oficina del Censo de los EE. UU. está obligada por ley a proteger su
información. A la Oficina del Censo no se le permite divulgar sus respuestas
de manera que usted o su hogar pudieran ser identificados. Estamos realizando
el Censo del 2020 en conformidad con las Secciones 141, 193, 221 y 223 del
Título 13 del Código de los EE. UU. Por ley, la Oficina del Censo solo puede
usar sus respuestas para producir estadísticas. Según la Ley Federal para el
Fortalecimiento de la Seguridad Informática de 2015, sus datos están
protegidos de los riesgos de la seguridad en la internet mediante controles en
los sistemas que transmiten sus datos.

Para obtener más información sobre cómo protegemos su información, visite
nuestro sitio web census.gov y haga clic en “Data Protection and Privacy
Policy” (Normas de protección de datos y privacidad) en la parte inferior de la
página principal. La página sobre protección de datos y normas deprivacidad
también incluye información sobre la recopilación, almacenamiento y uso de
esos registros. Haga clic en "System of Records Notices (SORN)" (Avisos sobre
el Sistema de Registros Escritos) y busque Privacy Act System of Records
Notice COMMERCE/CENSUS-5, Decennial Census Program (Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad COMMERCE/CENSUS-5,
Programa del Censo Decenal).

PARA USO DEL ENUMERADOR SOLAMENTE
Identificación del caso

Núm. de punto en el mapa

PARA USO DEL ENUMERADOR SOLAMENTE
Identificación del caso

Núm. de punto en el mapa

Draft 4 (7-10-2018)

D-JA-AS

(7-10-2018)

ENUMERATOR FLASHCARD

AF
T

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-JA-AS - Base prints Black Ink

WHO TO COUNT

RELATIONSHIP

We need to count people where
they live and sleep most of the time.

How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

Do NOT include:

Do include:

Same-sex husband/wife/spouse

●

College students who live
away from this address
most of the year

AF
T

Same-sex unmarried partner

● Babies and children

living here, including
foster children

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

●

● Roommates
● Boarders

People in a nursing home,
mental hospital, etc.
on April 1, 2020

People in jail, prison,
detention facility, etc.
on April 1, 2020

Brother or sister

Father or mother
Grandchild

● People staying here

on April 1, 2020 who
have no permanent
place to live

●

Armed Forces personnel
who live away

●

Parent-in-law

Son-in-law or daughter-in-law
Other relative
Roommate or housemate
Foster child
Other nonrelative

Page 2

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

HISPANIC ORIGIN

RACE

Is this person of Hispanic, Latino, or Spanish origin?

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

American Indian or Alaska Native – Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native
Village of Barrow Inupiat Traditional Government, Nome Eskimo
Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Page 3

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

BUILDING TYPE

INTERNET

Which best describes this building?

At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?

Include all apartments, flats, etc., even if vacant.

A mobile home

Yes

A one-family house detached from any other house

No ➜ SKIP to question 12

A one-family house attached to one or more houses

Three or more houses (American Samoa only)
A building with 2 apartments

Yes

No ➜ SKIP to question 12

A building with 3 or 4 apartments

Do you or any member of this household have access to the
Internet using a –
Yes

A building with 5 to 9 apartments
A building with 10 to 19 apartments

a. Cellular data plan for a smartphone or other
mobile device?

A building with 20 to 49 apartments

A building with 50 or more apartments
Boat, RV, van, etc.

AF
T

Two houses (American Samoa only)

Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?

COMPUTER USE

b. Broadband (high speed) Internet service such as
cable, fiber optic, or DSL service installed in this
household?
c. Satellite Internet service installed in this household?
d. Dial-up Internet service installed in this household?
e. Some other service? – Specify service C

At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?

Yes

a. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C

Page 4

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

SOURCE OF WATER

SEWAGE DISPOSAL

In 2019, did this house, apartment, or mobile home get water
K all that apply.
J
from – Mark I

What is the MAIN means of sewage disposal for this house,
K ONE box.
J
apartment, or mobile home? Mark I
Public sewer

A cistern, catchment, tanks, or drums?

Septic tank or cesspool

A delivery vendor or water truck?

Other

A supermarket or grocery store?

AF
T

A public system?

Some other source (a standpipe, spring, individual well, etc.)?

Page 5

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

CITIZEN or NATIONAL

Is this person a citizen or national of the United States?

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school this person has
J
K ONE box. If currently enrolled,
COMPLETED? – Mark I

Yes, born in American Samoa ➜ SKIP to question 11a

mark the previous grade or highest degree received.

Yes, born in another U.S. state or territory

NO SCHOOLING COMPLETED

Yes, born abroad of U.S. citizen or U.S. national parent or parents

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

Yes, U.S. citizen by naturalization – Print year
of naturalization C

No schooling completed

Nursery school, preschool or pre-kindergarten
Kindergarten

No, not a U.S. citizen or U.S. national (permanent resident)

Grade 1 through 11 – Specify grade 1 – 11 C

No, not a U.S. citizen or U.S. national (temporary resident)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

COLLEGE OR SOME COLLEGE
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)

Page 6

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

HEALTH INSURANCE

PERIOD OF SERVICE

When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.

Is this person 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

a. Insurance through a current or former employer
or union (of this person or another family member)

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by this person or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

h. Any other type of health insurance or health
coverage plan – Specify C

Page 7

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

TRANSPORTATION TO WORK

How did this person usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment
this person had last week.
If this person had more than one job, describe the one at which
the most hours were worked. If this person did not work last
week, describe the most recent employment in the past five
years (since 2015).

Public van/bus
Taxicab

Bicycle
Walked

AF
T

Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Plane or seaplane

For-pro t company or organization

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
Other method

TYPE OF WORKER

Non-pro t organization (including tax-exempt and charitable
organizations)

GOVERNMENT EMPLOYEE

Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee

SELF-EMPLOYED OR OTHER
Owner of non-incorporated business, professional
practice,or farm
Owner of incorporated business, professional practice,
or farm
Worked without pay in a for-pro t family business or farm
for 15 hours or more per week

Page 8

FORM D-JA-AS (7-10-2018)

D-JA-AS - Base prints Black Ink

D-JA-AS - Tone prints Pantone #6 Cyan 10% and 20%

Draft 1 (7-11-2018)

D-JA-MI

(7-11-2018)

ENUMERATOR FLASHCARD

AF
T

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-JA-MI - Base prints Black Ink

WHO TO COUNT

RELATIONSHIP

We need to count people where
they live and sleep most of the time.

How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

Do NOT include:

Do include:

Same-sex husband/wife/spouse

●

College students who live
away from this address
most of the year

AF
T

Same-sex unmarried partner

● Babies and children

living here, including
foster children

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

●

● Roommates
● Boarders

People in a nursing home,
mental hospital, etc.
on April 1, 2020

People in jail, prison,
detention facility, etc.
on April 1, 2020

Brother or sister

Father or mother
Grandchild

● People staying here

on April 1, 2020 who
have no permanent
place to live

●

Armed Forces personnel
who live away

●

Parent-in-law

Son-in-law or daughter-in-law
Other relative
Roommate or housemate
Foster child
Other nonrelative

Page 2

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

HISPANIC ORIGIN

RACE

Is this person of Hispanic, Latino, or Spanish origin?

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Page 3

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

BUILDING TYPE

INTERNET

Which best describes this building?

At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?

Include all apartments, flats, etc., even if vacant.

A mobile home

Yes

A one-family house detached from any other house

No ➜ SKIP to question 12

A one-family house attached to one or more houses

Three or more houses (American Samoa only)
A building with 2 apartments

Yes

No ➜ SKIP to question 12

A building with 3 or 4 apartments

Do you or any member of this household have access to the
Internet using a –
Yes

A building with 5 to 9 apartments
A building with 10 to 19 apartments

a. Cellular data plan for a smartphone or other
mobile device?

A building with 20 to 49 apartments

A building with 50 or more apartments
Boat, RV, van, etc.

AF
T

Two houses (American Samoa only)

Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?

COMPUTER USE

At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?

Yes

a. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C

Page 4

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

SOURCE OF WATER

SEWAGE DISPOSAL

In 2019, did this house, apartment, or mobile home get water
K all that apply.
J
from – Mark I

What is the MAIN means of sewage disposal for this house,
K ONE box.
J
apartment, or mobile home? Mark I
Public sewer

A cistern, catchment, tanks, or drums?

Septic tank or cesspool

A delivery vendor or water truck?

Other

A supermarket or grocery store?

AF
T

A public system?

Some other source (a standpipe, spring, individual well, etc.)?

Page 5

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

CITIZEN or NATIONAL

Is this person a citizen or national of the United States?
Yes, born in the Commonwealth of the Northern Mariana
Islands ➜ SKIP to question 11a
Yes, born in another U.S. state or territory

mark the previous grade or highest degree received.

NO SCHOOLING COMPLETED

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

of naturalization C

What is the highest degree or level of school this person has
J
K ONE box. If currently enrolled,
COMPLETED? – Mark I

No schooling completed

Yes, born abroad of U.S. citizen or U.S. national parent or parents
Yes, U.S. citizen by naturalization – Print year

HIGHEST DEGREE or LEVEL OF SCHOOL

Nursery school, preschool or pre-kindergarten
Kindergarten

No, not a U.S. citizen or U.S. national (permanent resident)

Grade 1 through 11 – Specify grade 1 – 11 C

No, not a U.S. citizen or U.S. national (temporary resident)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

Page 6

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

HEALTH INSURANCE

PERIOD OF SERVICE

When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.

Is this person 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

a. Insurance through a current or former employer
or union (of this person or another family member)

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by this person or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

h. Any other type of health insurance or health
coverage plan – Specify C

Page 7

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

TRANSPORTATION TO WORK

How did this person usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle
Walked

AF
T

Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Plane or seaplane

For-pro t company or organization

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
Other method

TYPE OF WORKER

Non-pro t organization (including tax-exempt and charitable
organizations)

GOVERNMENT EMPLOYEE

Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee

Page 8

FORM D-JA-MI (7-11-2018)

D-JA-MI - Base prints Black Ink

D-JA-MI - Tone prints Pantone #6 Cyan 10% and 20%

Draft 1 (7-11-2018)

D-JA-GU

(7-11-2018)

ENUMERATOR FLASHCARD

AF
T

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-JA-GU - Base prints Black Ink

WHO TO COUNT

RELATIONSHIP

We need to count people where
they live and sleep most of the time.

How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

Do NOT include:

Do include:

Same-sex husband/wife/spouse

●
t

College students who live
away from this address
m

AF
T

Same-sex unmarried partner

● Babies and children
o

living here, including
foster children

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

●

● Roommates
● Boarders

People in a nursing home,
mental hospital, etc.
on April 1, 2020

People in jail, prison,
detention facility, etc.
on April 1, 2020

Brother or sister

Father or mother
Grandchild

● People staying here

on April 1, 2020 who
have no permanent
place to live

●

Armed Forces personnel
who live away

●

Parent-in-law

Son-in-law or daughter-in-law
Other relative
Roommate or housemate
Foster child
Other nonrelative

Page 2

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

HISPANIC ORIGIN

RACE

Is this person of Hispanic, Latino, or Spanish origin?

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Page 3

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

BUILDING TYPE

INTERNET

Which best describes this building?

At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?

Include all apartments, flats, etc., even if vacant.

A mobile home

Yes

A one-family house detached from any other house

No ➜ SKIP to question 12

A one-family house attached to one or more houses

Three or more houses (American Samoa only)
A building with 2 apartments

Yes

No ➜ SKIP to question 12

A building with 3 or 4 apartments

Do you or any member of this household have access to the
Internet using a –
Yes

A building with 5 to 9 apartments
A building with 10 to 19 apartments

a. Cellular data plan for a smartphone or other
mobile device?

A building with 20 to 49 apartments

A building with 50 or more apartments
Boat, RV, van, etc.

AF
T

Two houses (American Samoa only)

Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?

COMPUTER USE

At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?

Yes

a. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C

Page 4

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

SOURCE OF WATER

SEWAGE DISPOSAL

In 2019, did this house, apartment, or mobile home get water
K all that apply.
J
from – Mark I

What is the MAIN means of sewage disposal for this house,
K ONE box.
J
apartment, or mobile home? Mark I
Public sewer

A cistern, catchment, tanks, or drums?

Septic tank or cesspool

A delivery vendor or water truck?

Other

A supermarket or grocery store?

AF
T

A public system?

Some other source (a standpipe, spring, individual well, etc.)?

Page 5

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

CITIZEN or NATIONAL

Is this person a citizen or national of the United States?

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school this person has
J
K ONE box. If currently enrolled,
COMPLETED? – Mark I

Yes, born in Guam ➜ SKIP to question 11a

mark the previous grade or highest degree received.

Yes, born in another U.S. state or territory

NO SCHOOLING COMPLETED

Yes, born abroad of U.S. citizen or U.S. national parent or parents

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

Yes, U.S. citizen by naturalization – Print year
of naturalization C

No schooling completed

Nursery school, preschool or pre-kindergarten
Kindergarten

No, not a U.S. citizen or U.S. national (permanent resident)

Grade 1 through 11 – Specify grade 1 – 11 C

No, not a U.S. citizen or U.S. national (temporary resident)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

Page 6

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

HEALTH INSURANCE

PERIOD OF SERVICE

When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.

Is this person 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

a. Insurance through a current or former employer
or union (of this person or another family member)

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by this person or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

h. Any other type of health insurance or health
coverage plan – Specify C

Page 7

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

TRANSPORTATION TO WORK

How did this person usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle
Walked

AF
T

Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Plane or seaplane

For-pro t company or organization

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
Other method

TYPE OF WORKER

Non-pro t organization (including tax-exempt and charitable
organizations)

GOVERNMENT EMPLOYEE

Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee

Page 8

FORM D-JA-GU (7-11-2018)

D-JA-GU - Base prints Black Ink

D-JA-GU - Tone prints Pantone #6 Cyan 10% and 20%

Draft 1 (7-11-2018)

D-JA-VI

(7-11-2018)

ENUMERATOR FLASHCARD

AF
T

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

D-JA-VI - Base prints Black Ink

WHO TO COUNT

RELATIONSHIP

We need to count people where
they live and sleep most of the time.

How is this person related to Person 1? Mark I
K ONE box.
J
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner

Do NOT include:

Do include:

Same-sex husband/wife/spouse

●

College students who live
away from this address
most of the year

AF
T

Same-sex unmarried partner

● Babies and children

living here, including
foster children

Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter

●

● Roommates
● Boarders

People in a nursing home,
mental hospital, etc.
on April 1, 2020

People in jail, prison,
detention facility, etc.
on April 1, 2020

Brother or sister

Father or mother
Grandchild

● People staying here

on April 1, 2020 who
have no permanent
place to live

●

Armed Forces personnel
who live away

●

Parent-in-law

Son-in-law or daughter-in-law
Other relative
Roommate or housemate
Foster child
Other nonrelative

Page 2

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

HISPANIC ORIGIN

RACE

Is this person of Hispanic, Latino, or Spanish origin?

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

No, not of Hispanic, Latino, or Spanish origin
White – Print, for example, German, Irish, English, Italian, Lebanese,
Egyptian, etc. C

Yes, Mexican, Mexican Am., Chicano

Yes, Cuban

AF
T

Yes, Puerto Rican

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –

Other Pacific Islander –

Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Page 3

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

BUILDING TYPE

INTERNET

Which best describes this building?

At this house, apartment, or mobile home – do you or any
member of this household have access to the Internet?

Include all apartments, flats, etc., even if vacant.

A mobile home

Yes

A one-family house detached from any other house

No ➜ SKIP to question 12

A one-family house attached to one or more houses

Three or more houses (American Samoa only)
A building with 2 apartments

Yes

No ➜ SKIP to question 12

A building with 3 or 4 apartments

Do you or any member of this household have access to the
Internet using a –
Yes

A building with 5 to 9 apartments
A building with 10 to 19 apartments

a. Cellular data plan for a smartphone or other
mobile device?

A building with 20 to 49 apartments

A building with 50 or more apartments
Boat, RV, van, etc.

AF
T

Two houses (American Samoa only)

Do you or any member of this household pay a cell phone
company or Internet service provider to access the
Internet?

COMPUTER USE

At this house, apartment, or mobile home – do you or any
member of this household own or use any of the following
types of computers?

Yes

a. Desktop or laptop
b. Smartphone
c. Tablet or other portable wireless computer
d. Some other type of computer – Specify C

Page 4

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

SOURCE OF WATER

SEWAGE DISPOSAL

In 2019, did this house, apartment, or mobile home get water
K all that apply.
J
from – Mark I

What is the MAIN means of sewage disposal for this house,
K ONE box.
J
apartment, or mobile home? Mark I
Public sewer

A cistern, catchment, tanks, or drums?

Septic tank or cesspool

A delivery vendor or water truck?

Other

A supermarket or grocery store?

AF
T

A public system?

Some other source (a standpipe, spring, individual well, etc.)?

Page 5

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

CITIZEN or NATIONAL

Is this person a citizen or national of the United States?

HIGHEST DEGREE or LEVEL OF SCHOOL

What is the highest degree or level of school this person has
J
K ONE box. If currently enrolled,
COMPLETED? – Mark I

Yes, born in the U.S. Virgin Islands ➜ SKIP to question 11a

mark the previous grade or highest degree received.

Yes, born in another U.S. state or territory

NO SCHOOLING COMPLETED

Yes, born abroad of U.S. citizen or U.S. national parent or parents

NURSERY OR PRESCHOOL THROUGH GRADE 12

AF
T

Yes, U.S. citizen by naturalization – Print year
of naturalization C

No schooling completed

Nursery school, preschool or pre-kindergarten
Kindergarten

No, not a U.S. citizen or U.S. national (permanent resident)

Grade 1 through 11 – Specify grade 1 – 11 C

No, not a U.S. citizen or U.S. national (temporary resident)

12th grade – NO DIPLOMA

HIGH SCHOOL GRADUATE

Regular high school diploma
GED or alternative credential

Doctorate degree (for example: PhD, EdD)

Page 6

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

HEALTH INSURANCE

PERIOD OF SERVICE

When did this person serve on active duty in the U.S. Armed
Forces? Mark I
K a box for EACH period in which this person
J
served, even if just for part of the period.

Is this person 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

a. Insurance through a current or former employer
or union (of this person or another family member)

August 1990 to August 2001 (including Persian Gulf War)
May 1975 to July 1990

AF
T

b. Insurance purchased directly from an insurance
company (by this person or another family member)

September 2001 or later

Vietnam Era (August 1964 to April 1975)
February 1955 to July 1964

c. Medicare, for people 65 and older, or people
with certain disabilities

Korean War (July 1950 to January 1955)
January 1947 to June 1950

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
e. TRICARE or other military health care

g. Indian Health Service

November 1941 or earlier

f. VA (enrolled for VA health care)

World War II (December 1941 to December 1946)

h. Any other type of health insurance or health
coverage plan – Specify C

Page 7

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

TRANSPORTATION TO WORK

How did this person usually get to work LAST WEEK?
Mark I
K ONE box for the method of transportation used for
J
most of the distance.
Car, truck, or private van/bus

Public van/bus
Taxicab

Bicycle
Walked

AF
T

Which one of the following best describes this person’s
employment last week or the most recent employment
in the past 5 years (since 2015)? Mark I
K ONE box.
J

Motorcycle

PRIVATE SECTOR EMPLOYEE

Plane or seaplane

For-pro t company or organization

Boat, ferry, or water taxi
Worked from home ➜ SKIP to question 43a
Other method

TYPE OF WORKER

Non-pro t organization (including tax-exempt and charitable
organizations)

GOVERNMENT EMPLOYEE

Local or territorial government (for example: public
elementary school)
Active duty U.S. Armed Forces or Commissioned Corps
Federal government civilian employee

Page 8

FORM D-JA-VI (7-11-2018)

D-JA-VI - Base prints Black Ink

D-JA-VI - Tone prints Pantone #6 Cyan 10% and 20%

Draft 2 (8-2-2018)

D-JA-VI(S)

(8-2-2018)

TARJETA DE REFERENCIA PARA
ENUMERADORES

AF
T

Núm. de OMB xxxx-xxxx: Aprobado hasta xx/xx/xxxx

D-JA-VI(S) - Base prints Black Ink

A QUIÉN CONTAR

PARENTESCO

Necesitamos contar a las personas
donde viven y duermen la mayor
parte del tiempo.

¿Cómo está esta persona relacionada con la Persona 1?
Marque I
K UNA casilla.
J
Esposo(a) del sexo opuesto
Pareja no casada del sexo opuesto

NO incluya:

Incluya:

Esposo(a) del mismo sexo

●
●

● Bebés y niños que viven aquí,

Personal de las Fuerzas
Armadas que vive fuera
de aquí.

● Compañeros de casa o
cuarto.

Personas que estaban en un
hogar de ancianos o nursing
home, un hospital para
enfermos mentales, etc. el
1 de abril de 2020.
Personas que estaban en
una cárcel, una prisión, un
centro de detención, etc.
el 1 de abril de 2020.

incluyendo a hijos de crianza
(foster).

● Inquilinos.

● Personas que se quedaban
aquí el 1 de abril de 2020
y que no tienen lugar
permanente donde vivir.

●

Estudiantes universitarios que
no viven en esta dirección la
mayor parte del año.

●

AF
T

Pareja no casada del mismo sexo
Hijo(a) biológico(a) o de sangre
Hijo(a) adoptivo(a)
Hijastro(a)

Hermano(a)

Padre o madre
Nieto(a)

Suegro(a)

Yerno o nuera
Otro pariente

Roommate o compañero(a) de casa
Hijo(a) foster
Otra persona que no es pariente

Página 2

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

ORIGEN HISPANO

RAZA

¿Es esta persona de origen hispano, latino o español?

¿Cuál es la raza de esta persona?
Marque I
K una o más casillas Y escriba los orígenes.
J

No, no es de origen hispano, latino o español
Blanca – Escriba, por ejemplo, alemán, irlandés, inglés, italiano,
libanés, egipcio, etc. C

Sí, mexicano, mexicanoamericano, chicano

Sí, cubano

AF
T

Sí, puertorriqueño

Sí, de otro origen hispano, latino o español – Escriba, por ejemplo,
salvadoreño, dominicano, colombiano, guatemalteco, español,
ecuatoriano, etc. C

Negra o afroamericana – Escriba, por ejemplo, afroamericano,
jamaiquino, haitiano, nigeriano, etíope, somalí, etc. C

Indígena de las Américas o nativa de Alaska – Escriba el nombre
de la(s) tribu(s) en la(s) que está inscrita o la(s) tribu(s) principal(es),
por ejemplo, Navajo Nation, Blackfeet Tribe, maya, azteca, Native
Village of Barrow Inupiat Traditional Government, Nome Eskimo
Community, etc. C

China

Vietnamita

Nativa de Hawái

Filipina

Coreana

Samoana

India asiática

Japonesa

Chamorra

Otra asiática –
Escriba, por ejemplo,
pakistaní, camboyano,
hmong, etc. C

Otra de las islas del
Pacifico – Escriba, por
ejemplo, tongano, fiyiano,
de las Islas Marshall, etc. C

Alguna otra raza – Escriba la raza o el origen. C

Página 3

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

TIPO DE EDIFICIO

INTERNET

¿Cuál describe mejor este edificio? Incluya todos los apartamentos,
pisos, etc., aunque estén desocupados.

En esta casa, apartamento o casa móvil, ¿tiene usted o algún otro
miembro de este hogar acceso a internet?

Una casa móvil

Sí

Una casa para una sola familia, separada de otras casas

No ➜ PASE a la pregunta 12

Dos casas (Samoa Estadounidense solamente)

Tres o más casas (Samoa Estadounidense solamente)
Un edificio con 2 apartamentos

¿Paga usted o algún otro miembro de este hogar a una empresa de
telefonía celular o a un proveedor de servicio de internet para tener
acceso a internet?

AF
T

Una casa para una sola familia, unida a una o más casas

Sí

No ➜ PASE a la pregunta 12

Un edificio con 3 o 4 apartamentos

¿Tiene usted o algún otro miembro de este hogar acceso
a internet a través de un –

Un edificio con 5 a 9 apartamentos
Un edificio con 10 a 19 apartamentos
Un edificio con 20 a 49 apartamentos

Un edificio con 50 o más apartamentos
Embarcación, vehículo recreativo (RV), van, etc.

USO DE COMPUTADORA

En esta casa, apartamento o casa móvil, ¿tiene o usa usted o algún
otro miembro de este hogar alguno de los siguientes tipos de
computadoras?
Sí
No

Sí

a. Plan de datos celulares para un teléfono inteligente u otro
dispositivo móvil?

b. Servicio de internet de banda ancha
(alta velocidad) tales como servicio de cable,
fibra óptica o DSL instalado en este hogar?
c. Servicio de internet por satélite instalado en este hogar?
d. Servicio de internet de conexión Dial-up
instalado en este hogar?
e. Algun otro servicio? – Especifique el servicio C

a. Computadora de escritorio o computadora portátil
b. Teléfono inteligente
c. Tableta u otra computadora inalámbrica portátil
d. Algún otro tipo de computadora – Especifique C

Página 4

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

FUENTE DE AGUA

ELIMINACIÓN DE AGUAS RESIDUALES

En 2019, ¿esta casa, apartamento o casa móvil recibió aqua de –
Marque I
K a^ todas las opciones que correspondan.
J

¿Cuál es el medio PRINCIPAL de eliminación de aguas cloacales de
esta casa, apartamento o casa móvil? Marque I
K UNA casilla.
J
Alcantarillado o desagüe público

Una cisterna, zona de captación de agua, tanques o tambores?

Tanque séptico o pozo ciego

Un servicio de entrega o un camión cisterna?

Otro

Un supermercado o tienda de comestibles?

Alguna otra fuente (un tubo vertical, manantial,
pozo individual, etc.)?

AF
T

Un sistema público?

Página 5

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

CIUDADANO(A) o NACIONAL

¿Es esta persona ciudadana o nacional de los Estados Unidos?
Sí, nacido(a) en las Islas Vírgenes de los EE. UU. ➜ PASE a la
pregunta 11a
Sí, nacido(a) en otro estado o territorio de los EE. UU.

Sí, es ciudadano(a) de los EE. UU. por naturalización – Escriba el
año de naturalización. C

No, no es ciudadano(a) o nacional de los EE. UU.
(residente permanente)
No, no es ciudadano(a) o nacional de los EE. UU.
(residente temporal)

¿Cuál es el grado o nivel de educación más alto que esta persona ha
completado? Marque I
K UNA casilla. Si está matriculada actualmente, marque
J
el grado escolar anterior o el título más alto recibido.

NO HA COMPLETADO NINGÚN GRADO
No ha completado ningún grado
GUARDERÍA O PREESCOLAR HASTA GRADO 12

AF
T

Sí, nacido(a) en el extranjero de padre o madre que es
ciudadano(a) o nacional de los EE. UU.

GRADO o NIVEL DE EDUCACIÓN MÁS ALTO

Guardería, preescolar o prekindergarten
Kindergarten

Grado 1 al 11 – Especifique el grado, del 1 al 11 C

Grado 12 – SIN DIPLOMA

GRADUADO(A) DE ESCUELA SECUNDARIA O PREPARATORIA

Diploma de escuela secundaria o preparatoria
GED o examen equivalente

UNIVERSIDAD O ALGUNOS CRÉDITOS UNIVERSITARIOS
Algunos créditos universitarios, pero menos de 1 año de
créditos universitarios
1 año o más de créditos universitarios, sin título
Título asociado universitario (por ejemplo: AA, AS)
Título de licenciatura universitaria (por ejemplo: BA, BS)
DESPUÉS DEL TÍTULO DE LICENCIATURA UNIVERSITARIA
Título de maestría (por ejemplo: MA, MS, MEng, MEd, MSW, MBA)
Título profesional más allá de un título de licenciatura
universitaria (por ejemplo: MD, DDS, DVM, LLB, JD)
Título de doctorado (por ejemplo: PhD, EdD)

Página 6

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

SEGURO MÉDICO

PERÍODO DE SERVICIO

¿Tiene esta persona cobertura ACTUALMENTE de alguno de los
siguientes tipos de seguros de salud o planes de cobertura de
salud? Marque “Sí” o “No” para CADA tipo de cobertura en las
respuestas a – h.
Sí
No

d. Medicaid, Medical Assistance o cualquier tipo
de plan de asistencia gubernamental para
personas con bajos ingresos o con discapacidad
e. TRICARE u otro seguro de salud militar

Época de Vietnam (agosto del 1964 a abril del 1975)

Febrero del 1955 a julio del 1964

Guerra de Corea (julio del 1950 a enero del 1955)
Enero del 1947 a junio del 1950

Segunda Guerra Mundial (diciembre del 1941 a diciembre
del 1946)
Noviembre del 1941 o antes

f. Administración de Veteranos (VA) (se ha
inscrito en el sistema de cuidado de salud
militar de la VA)

Mayo del 1975 a julio del 1990

AF
T

c. Medicare, para personas que tienen 65 años o
más, o personas con ciertas discapacidades

Septiembre del 2001 o después
Agosto del 1990 a agosto del 2001 (incluyendo la Guerra del
Golfo Pérsico)

a. Seguro a través de su empleador o sindicato
(union), actual o previo (de esta persona o de
cualquier otro miembro de la familia)
b. Seguro adquirido directamente de una compañía de
seguro (por esta persona o por cualquier otro
miembro de la familia)

¿Cuándo prestó esta persona servicio activo en las Fuerzas Armadas
de los EE. UU.? Marque I
K una casilla para CADA período durante el
J
cual esta persona prestó servicio, aunque fuera solo por parte del período.

g. Servicio de Salud Indo (Indian Health Service)

h. Cualquier otro tipo de seguro de salud o plan de
cobertura de salud – Especifique C

Página 7

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

TRANSPORTE AL TRABAJO

¿Cómo llegó esta persona habitualmente al trabajo LA SEMANA
PASADA? Marque I
K UNA casilla para el medio de transporte que utilizó
J
por más distancia.

TIPO DE TRABAJADOR

DESCRIPCIÓN DEL EMPLEO
La siguiente serie de preguntas se refiere al tipo de empleo que esta
persona tenía la semana pasada.
Si esta persona tenía más de un empleo, describa el empleo en el
cual la persona trabajó más horas. Si esta persona no tenía empleo
la semana pasada, describa su empleo más reciente en los últimos
cinco años (desde 2015).

Automóvil, camión o van/autobús privado
Van/autobús público
Taxi

Bicicleta
Caminó

AF
T

a. ¿Cuál de las siguientes opciones describe mejor el empleo de esta
persona la semana pasada o el empleo más reciente en los últimos
cinco años (desde 2015)? Marque I
K UNA casilla.
J

Motocicleta

EMPLEADO(A) DEL SECTOR PRIVADO

Avión o hidroavión

Empresa u organización con

Lancha, ferri o taxi acuático

Trabajó en el hogar ➜ PASE a la pregunta 43a
Otro método

nes de lucro

Organización sin nes de lucro (incluso organizaciones
exentas de impuestos y organizaciones benéficas)

EMPLEADO(A) DEL GOBIERNO

Gobierno local o territorial
(por ejemplo: escuela primaria pública)
Servicio activo en las Fuerzas Armadas o en los
Cuerpos Comisionados de los EE. UU.
Empleado(a) civil del gobierno federal

EMPLEADO(A) POR CUENTA PROPIA U OTRO TIPO
DE EMPLEO
Dueño(a) de un negocio, práctica profesional o finca
no incorporados
Dueño(a) de un negocio, práctica profesional o finca
incorporados
Trabajo sin paga en un negocio o finca de la familia
con nes de lucro 15 horas o más por semana

Página 8

FORM D-JA-VI(S) (8-2-2018)

D-JA-VI(S) - Base prints Black Ink

D-JA-VI(S) - Tone prints Pantone #6 Cyan 10% and 20%

DC
Your Answers Are Con dential
The U.S. Census Bureau is required by law to protect your information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify you. We are conducting the 2020 Census under the authority of
Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use your responses to produce statistics. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems
that transmit your data.
Title 13 of the U.S. Code protects the con dentiality of all your information. Violating the con dentiality of a respondent is a federal
crime with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information you provide to the Census Bureau may only be used by a restricted number
of authorized individuals who are sworn for life to protect the con dentiality of your individual responses. Your answers cannot be used
against you by any government agency or court.
For more information about how we protect your information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.

Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project XXXX-XXXX,
U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments to
<2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" as the subject.

FORM

D-CN-AS (6-14-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

The U.S. Census Bureau is required by law to protect your information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify you. We are conducting the 2020 Census under the authority of
Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use your responses to produce statistics. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems
that transmit your data.
Title 13 of the U.S. Code protects the con dentiality of all your information. Violating the con dentiality of a respondent is a federal
crime with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information you provide to the Census Bureau may only be used by a restricted number
of authorized individuals who are sworn for life to protect the con dentiality of your individual responses. Your answers cannot be used
against you by any government agency or court.
For more information about how we protect your information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.
You are required by law to respond to the 2020 Census (Title 13, U.S. Code, Sections 141 and 193). The Census Bureau
estimates that completing the questionnaire will take 40 minutes on average. This collection of information has been approved by
the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the bottom left of this notice
confirms this approval. If this number were not displayed, we could not conduct the census.
Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project XXXX-XXXX,
U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments to
<2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" as the subject.

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-AS (6-14-2018)

FORM

D-CN-MI (6-14-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-MI (6-14-2018)

FORM

D-CN-GU (6-14-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-GU (6-14-2018)

AF
T

You are required by law to respond to the 2020 Census (Title 13, U.S. Code, Sections 141 and 193). The Census Bureau
estimates that completing the questionnaire will take 40 minutes on average. This collection of information has been approved by
the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the bottom left of this notice
confirms this approval. If this number were not displayed, we could not conduct the census.
Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project XXXX-XXXX,
U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments to
<2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" as the subject.
Para ver esta información en español, véase al dorso. (For a copy of this information in Spanish, see the reverse side.)

FORM

D-CN-VI(E/S) (6-14-2018)

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

Your Answers Are Con dential
The U.S. Census Bureau is required by law to protect your information (Title 13, U.S. Code, Section 9). The Census Bureau is not
permitted to publicly release your responses in a way that could identify you. We are conducting the 2020 Census under the authority of
Title 13, U.S. Code, Sections 141, 193, 221 and 223. By law, the Census Bureau can only use your responses to produce statistics. Per
the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems
that transmit your data.
Title 13 of the U.S. Code protects the con dentiality of all your information. Violating the con dentiality of a respondent is a federal
crime with serious penalties, including a federal prison sentence of up to ve years, a ne of up to $250,000, or both. Only authorized
individuals have access to the stored data, and the information you provide to the Census Bureau may only be used by a restricted number
of authorized individuals who are sworn for life to protect the con dentiality of your individual responses. Your answers cannot be used
against you by any government agency or court.
For more information about how we protect your information, please visit our Web site at census.gov and click on "Data Protection and
Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and use of these
records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/CENSUS-5,
Decennial Census Program.
Thank you for your cooperation. The Census Bureau appreciates your help.
You are required by law to respond to the 2020 Census (Title 13, U.S. Code, Sections 141 and 193). The Census Bureau
estimates that completing the questionnaire will take 40 minutes on average. This collection of information has been approved by
the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the bottom left of this notice
confirms this approval. If this number were not displayed, we could not conduct the census.
Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project XXXX-XXXX,
U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments to
<2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" as the subject.
Para ver esta información en español, véase al dorso. (For a copy of this information in Spanish, see the reverse side.)
OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

FORM

D-CN-VI(E/S) (6-14-2018)

DC
Sus respuestas son con denciales
La O cina del Censo de los EE. UU. está obligada por ley a proteger su información. A la O cina del Censo no se le permite divulgar sus
respuestas de manera que usted pudiera ser identi cado. Estamos realizando el Censo del 2020 en conformidad con las Secciones 141, 193,
221 y 223 del Título 13 del Código de los EE. UU. Por ley, la O cina del Censo solo puede usar sus respuestas para producir estadísticas. En
conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética Federal del 2015, sus datos están protegidos contra los riesgos de
seguridad cibernética mediante los controles aplicados a los sistemas que los transmiten.
El Título 13 del Código de los EE. UU. protege la con dencialidad de toda su información. Violar la con dencialidad de una persona
encuestada es un delito federal que acarrea sanciones severas, incluso una sentencia de hasta cinco años en una prisión federal, una multa de
hasta $250,000, o ambas. Solo personas autorizadas tienen acceso a los datos almacenados, y la información que usted proporcione a la
O cina del Censo puede ser usada solamente por un número limitado de personas autorizadas que han jurado de por vida proteger la
con dencialidad de sus respuestas individuales. Sus respuestas no pueden ser usadas en su contra por ninguna agencia o tribunal del gobierno.
Para obtener más información sobre cómo protegemos su información, visite nuestro sitio web census.gov y haga clic en “Data Protection and
Privacy Policy” en la parte inferior de la página principal. La página sobre protección de datos y normas de privacidad también incluye
información sobre la recopilación, almacenamiento y uso de esos registros; haga clic en "System of Records Notices (SORN)" (Avisos sobre el
Sistema de Registros) y busque Privacy Act System of Records Notice COMMERCE/CENSUS-5, Decennial Census Program (Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad COMMERCE/CENSUS-5, Programa del Censo Decenal).
Gracias por su cooperación. La O cina del Censo agradece su ayuda.

AF
T

A usted se le requiere por ley que responda al Censo del 2020 (Secciones 141 y 193 del Título 13 del Código de los EE. UU.). La
Oficina del Censo calcula que completar el cuestionario tomará 40 minutos como promedio. Esta recopilación de información ha
sido aprobada por la Oficina de Administración y Presupuesto (OMB, por sus siglas en inglés). El número de aprobación de ocho
dígitos de la OMB aparece en la parte inferior izquierda de este aviso confirma la aprobación. De no mostrarse este número, no
podríamos realizar el censo.
Los comentarios sobre el cálculo de tiempo y esfuerzo o cualquier otro aspecto relacionado deben dirigirse a: Paperwork Reduction
Project XXXX-XXXX, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. Puede enviar comentarios
por correo electrónico a <2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" como tema.
For a copy of this information in English, see the reverse side. (Para ver esta información en inglés, véase al dorso.)

FORM

D-CN-VI(E/S) (6-14-2018)

Núm. de OMB XXXX-XXXX: Aprobado hasta XX/XX/XXXX

Sus respuestas son con denciales
La O cina del Censo de los EE. UU. está obligada por ley a proteger su información. A la O cina del Censo no se le permite divulgar sus
respuestas de manera que usted pudiera ser identi cado. Estamos realizando el Censo del 2020 en conformidad con las Secciones 141, 193,
221 y 223 del Título 13 del Código de los EE. UU. Por ley, la O cina del Censo solo puede usar sus respuestas para producir estadísticas. En
conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética Federal del 2015, sus datos están protegidos contra los riesgos de
seguridad cibernética mediante los controles aplicados a los sistemas que los transmiten.
El Título 13 del Código de los EE. UU. protege la con dencialidad de toda su información. Violar la con dencialidad de una persona
encuestada es un delito federal que acarrea sanciones severas, incluso una sentencia de hasta cinco años en una prisión federal, una multa de
hasta $250,000, o ambas. Solo personas autorizadas tienen acceso a los datos almacenados, y la información que usted proporcione a la
O cina del Censo puede ser usada solamente por un número limitado de personas autorizadas que han jurado de por vida proteger la
con dencialidad de sus respuestas individuales. Sus respuestas no pueden ser usadas en su contra por ninguna agencia o tribunal del gobierno.
Para obtener más información sobre cómo protegemos su información, visite nuestro sitio web census.gov y haga clic en “Data Protection and
Privacy Policy” en la parte inferior de la página principal. La página sobre protección de datos y normas de privacidad también incluye
información sobre la recopilación, almacenamiento y uso de esos registros; haga clic en "System of Records Notices (SORN)" (Avisos sobre el
Sistema de Registros) y busque Privacy Act System of Records Notice COMMERCE/CENSUS-5, Decennial Census Program (Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad COMMERCE/CENSUS-5, Programa del Censo Decenal).
Gracias por su cooperación. La O cina del Censo agradece su ayuda.
A usted se le requiere por ley que responda al Censo del 2020 (Secciones 141 y 193 del Título 13 del Código de los EE. UU.). La
Oficina del Censo calcula que completar el cuestionario tomará 40 minutos como promedio. Esta recopilación de información ha
sido aprobada por la Oficina de Administración y Presupuesto (OMB, por sus siglas en inglés). El número de aprobación de ocho
dígitos de la OMB aparece en la parte inferior izquierda de este aviso confirma la aprobación. De no mostrarse este número, no
podríamos realizar el censo.
Los comentarios sobre el cálculo de tiempo y esfuerzo o cualquier otro aspecto relacionado deben dirigirse a: Paperwork Reduction
Project XXXX-XXXX, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. Puede enviar comentarios
por correo electrónico a <2020.census.paperwork@census.gov>. Use "Paperwork Reduction Project XXXX-XXXX" como tema.
For a copy of this information in English, see the reverse side. (Para ver esta información en inglés, véase al dorso.)
Núm. de OMB XXXX-XXXX: Aprobado hasta XX/XX/XXXX

FORM

D-CN-VI(E/S) (6-14-2018)

File Type	application/pdf
Author	OneFormUser
File Modified	2018-12-27
File Created	2018-12-27