U.S. Department of Commerce

American Community Survey

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Explore the Form (Text Only Version)

Respond online today at:
https://respond.census.gov/acs
OR
Complete this form and mail it back as soon as possible.

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.

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.

¿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 pedir un cuestionario en español o completar su entrevista por teléfono con un entrevistador que habla español.

For more information about the American Community Survey, visit our web site at: http://www.census.gov/acs/www/

Start Here: Page 1

  • Please print today's date.
    Month Day Year
  • Please print the name and telephone number of the person who is filling out this form.
    We may contact you if there is a question.
    Last Name
    First Name
    MI
    Area Code + Number
  • 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.

PERSON 1-2: Page 2

(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.)

  1. What is Person 1's name?
    Last Name (Please print)
    First Name
    MI

    Why We Ask:

    We use this information to make sure responses to the survey are complete. We may follow-up to ask about incomplete or missing information on the form.

  2. How is this person related to Person 1?
    Person 1

    Why We Ask:

    We ask this question to produce statistics about families and other groups within households. Information about the make up of a family, from the number of seniors living alone to the number of children living with one parent or a grandparent, is essential for making decisions that impact funding for programs affecting families.

  3. What is Person 1's sex? Mark(X) ONE box.
    Male
    Female

    Why We Ask:

    We ask this question to get basic information about the distribution of males and females in a community. State and local planners can use this information to determine their future needs for employment, transportation, childcare, education, healthcare, and housing. Statistics about sex are also used to ensure equal access to economic opportunity, housing and education under federal law.

  4. 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)
    Month
    Day
    Year of Birth

    Why We Ask:

    We ask this question to get key information about children, adults, and seniors. Funds for education are distributed by the Federal Government to states based on age, and local governments can use these statistics to decide where and when schools should be built. Statistics on age are used to predict the need for Social Security and Medicare, and to allocate funds to seniors with low incomes under the Older Americans Act. Planners also use the data to forecast the need for hospitals, health services and senior centers.

    5. 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 1 of Hispanic, Latino, or Spanish origin?
    1. No, not of Hispanic, Latino, or Spanish origin
    2. Yes, Cuban
    3. Yes, Mexican, Mexican Am., Chicano
    4. Yes, Puerto Rican
    5. Yes, another Hispanic, Latino, or Spanish origin - Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.

    Why We Ask:

    We ask this question to generate statistics used to enforce equal treatment under the law for all. Statistics about Hispanic origin are used to enforce equal employment opportunity under the Civil Rights Act and equality of elections and voting under the Voting Rights Act.

  6. What is Person 1's race? Mark(X) one or more boxes.
    1. White
    2. American Indian or Alaska Native -- Print name of enrolled or principal tribe.
    3. Black, African Am., or Negro
    4. Asian Indian
    5. Chinese
    6. Filipino
    7. Other Asian - Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
    8. Japanese
    9. Korean
    10. Vietnamese
    11. Native Hawaiian
    12. Guamanian or Chamorro
    13. Samoan
    14. Other Pacific Islander - Print race, for example, Fijian, Tongan, and so on.
    15. Some other race - Print race.

    Why We Ask:

    We ask this question about race because it's critical to many policies. Statistics on race are used to guide funding decisions in programs that support equal opportunity in education, assess fairness of employment practices under the Civil Rights act, and help policy makers ensure everyone has equal access to health care. The Voting Rights Act is also enforced by using information gathered from questions about race.

  7. PERSON 2

    Why We Ask:

    Complete information for a second person in the household, if applicable. The "people" questions, pages 2-4 and pages 8-27, should be answered for each person in the household. If you have more than five people in your household, list them on page 4. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.


PERSON 3-4: Page 3

  • PERSON 3

    Why We Ask:

    Complete information for a third person in the household, if applicable. The "people" questions, pages 2-4 and pages 8-27, should be answered for each person in the household. If you have more than five people in your household, list them on page 4. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.

  • PERSON 4

    Why We Ask:

    Complete information for a fourth person in the household, if applicable. The "people" questions, pages 2-4 and pages 8-27, should be answered for each person in the household. If you have more than five people in your household, list them on page 4. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.


PERSON 5-12: Page 4

  • PERSON 5

    Why We Ask:

    Complete information for a fifth person in the household, if applicable. The "people" questions, pages 2-4 and pages 8-27, should be answered for each person in the household. If you have more than five people in your household, list them on page 4. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.

  • PERSON 6 - 12

    Why We Ask:

    If there are more than five people in your household, list them each here. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.


HOUSING: Page 5

Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

  1. Which best describes this building? Include all apartments, flats, etc., even if vacant.
    1. A mobile home
    2. A one-family house detached from any other house
    3. A one-family house attached to one or more houses
    4. A building with 2 apartments
    5. A building with 3 or 4 apartments
    6. A building with 5 to 9 apartments
    7. A building with 10 to 19 apartments
    8. A building with 20 to 49 apartments
    9. A building with 50 or more apartments
    10. Boat, RV, van, etc.

    Why We Ask:

    We ask this question to compile statistics about what type of housing is available in the U.S. houses, apartments, mobile homes or other structures. The Federal Government uses this information to set fair market rents for all areas of the country. State and local governments use this information to identify areas of the community that have a high concentration of mobile homes - helping them respond to hurricanes and tornados.

  2. About when was this building first built?
    1. 2000 or later - Specify year
    2. 1990 to 1999
    3. 1980 to 1989
    4. 1970 to 1979
    5. 1960 to 1969
    6. 1950 to 1959
    7. 1940 to 1949
    8. 1939 or earlier

    Why We Ask:

    We ask this question to help evaluate the quality of housing in the U.S. Statistics about a building's age help measure the existence of lower quality or substandard housing. Local governments also use information about the age of the structure to forecast the need for fire protection.

  3. When did PERSON 1 (listed on page 2) move into this house, apartment, or mobile home?
    Month Year

    Why We Ask:

    We ask this question in order to compile statistics about the mobility in neighborhoods to identify which areas are more transient. The statistics are used by state and local agencies to evaluate changes needed in community services and housing needs. Federal and local emergency management agencies use this information to assess the number of people who may be displaced by natural disasters.

    4. A. Answer questions 4 - 6 if this is a HOUSE OR A MOBILE HOME; otherwise, SKIP to question 7a.

  4. How many acres is this house or mobile home on?
    1. Less than 1 acre ➔ SKIP to question 6
    2. 1 to 9.9 acres
    3. 10 or more acres

    Why We Ask:

    We ask this question to identify America's farm population, and to distinguish between farm and nonfarm residences.

  5. IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?
    1. None
    2. $1 to $999
    3. $1,000 to $2,499
    4. $2,500 to $4,999
    5. $5,000 to $9,999
    6. $10,000 or more

    Why We Ask:

    We ask this question to identify America's farm population, and to distinguish between farm and nonfarm residences.

  6. Is there a business (such as a store or barber shop) or a medical office on this property?
    1. Yes
    2. No

    Why We Ask:

    We ask this question to produce accurate estimates of housing value. The value of home and property is an important measure of housing affordability and wealth. Because the existence of a business in a residential home may change its value, having this information helps create an accurate reflection of home value in an area.

  7. a. How many separate rooms are in this house, apartment, or mobile home? Rooms must be separated by built-in archways or walls that extend out at least 6 inches and go from floor to ceiling.
    Rooms must be separated by built-in archways or walls that extend out at least 6 inches and go from floor to ceiling.
    • INCLUDE bedrooms, kitchens, etc.
    • EXCLUDE bathrooms, porches, balconies, foyers, halls, or unfinished basements.
    Number of rooms     b. How many of these rooms are bedrooms?
    Count as bedrooms those rooms you would list if this house, apartment, or mobile home were for sale or rent. If this is an efficiency/studio apartment, print "0".

    Number of bedrooms

    Why We Ask:

    We ask these questions to measure the extent of overcrowding among U.S. households. City and community officials use local statistics about the number of people per room to determine whether there are housing deficiencies in neighborhoods. It's also used to allocate funds for housing assistance and home energy assistance to local governments.

  8. Does this house, apartment, or mobile home have - Yes No
    1. hot and cold running water?
    2. a flush toilet?
    3. a bathtub or shower?
    4. a sink with a faucet?
    5. a stove or range?
    6. a refrigerator?
    7. telephone service from which you can both make and receive calls? Include cell phones.

    Why We Ask:

    Government agencies use this information to make sure people have affordable, safe & sanitary housing, to determine fair market rates, and to determine whether an area is eligible for housing assistance or loans. Information on kitchen facilities is used to evaluate the effectiveness of programs that provide grants to local government for the rehabilitation of properties used as rentals. Information on plumbing is used by public health officials to locate areas in danger of groundwater contamination and to prevent the spread of waterborne disease. Information on telephone service is used to develop plans for emergency/911 services.

  9. At this house, apartment, or mobile home - do you or any member of this household own or use any of the following computers? - Yes No
    EXCLUDE GPS devices, digital music players, and devices with only limited computing capabilities, for example: household appliances.
    1. Desktop, laptop, netbook, or notebook computer
    2. Handheld computer, smart mobile phone, or other handheld wireless computer
    3. Some other type of computer Specify

    Why We Ask:

    We ask this question to create statistics about computer and Internet access throughout the country. Government agencies use these statistics to institute policies and programs that increase broadband access to areas with less connectivity by providing grants to expand public access and fund broadband education and support.

  10. At this house, apartment, or mobile home - do you or any member of this household access the Internet?
    1. Yes, with a subscription to an Internet service
    2. Yes, without a subscription to an Internet service ➔ SKIP to question 12
    3. No Internet access at this house, apartment, or mobile home ➔ SKIP to question 12

    Why We Ask:

    We ask this question to create statistics about computer and Internet access throughout the country. Government agencies use these statistics to institute policies and programs that increase broadband access to areas with less connectivity by providing grants to expand public access and fund broadband education and support.

  11. At this house, apartment, or mobile home - do you or any member of this household subscribe to the Internet using - Yes No
    1. Dial-up service?
    2. DSL service?
    3. Cable modem service?
    4. Fiber-optic service?
    5. Mobile broadband plan for a computer or a cell phone?
    6. Satellite Internet service?
    7. Some other service? Specify service

    Why We Ask:

    We ask this question to create statistics about computer and Internet access throughout the country. Government agencies use these statistics to institute policies and programs that increase broadband access to areas with less connectivity by providing grants to expand public access and fund broadband education and support.


HOUSING (continued): Page 6

  1. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?
    1. None
    2. 1
    3. 2
    4. 3
    5. 4
    6. 5
    7. 6 or more

    Why We Ask:

    We ask about the number of vehicles per household to evaluate transportation programs. Information about the number of vehicles available allows state and metropolitan transportation agencies to predict the effect of future travel on transportation systems. State and local agencies use this information to determine the special transportation needs of the elderly and disabled. Social service agencies use the statistics to plan for emergency transportation in areas where few household vehicles are available.

  2. Which FUEL is used MOST for heating this house, apartment, or mobile home?
    1. Gas: from underground pipes serving the neighborhood
    2. Gas: bottled, tank, or LP
    3. Electricity
    4. Fuel oil, kerosene, etc.
    5. Coal or coke
    6. Wood
    7. Solar energy
    8. Other fuel
    9. No fuel used

    Why We Ask:

    We ask this question to create statistics about energy supply and consumption. State and local environmental agencies use the estimates to identify areas that may have an interest in alternative fuels, such as solar energy. Utility companies use the estimates to predict the need for power facilities such as pipelines for oil or gas and transmission lines for electricity, and the federal government uses the estimates to assess whether the available energy sources meet the needs of the community.

  3. a. LAST MONTH, what was the cost of electricity for this house, apartment, or mobile home?
    Last month's cost - Dollars $ .00 OR Included in rent or condominium fee. No charge or electricity not used     b. LAST MONTH, what was the cost of gas for this house, apartment, or mobile home?
    Last month's cost - Dollars $ .00 OR Included in rent or condominium fee. Included in electricity payment entered above. No charge or gas not used     c. IN THE PAST 12 MONTHS, what was the cost of water and sewer for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost.
    Past 12 months' cost - Dollars $ .00 OR Included in rent or condominium fee. No charge     d. IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile If you have lived here less than 12 months, estimate the cost.
    Past 12 months' cost - Dollars $ .00 OR Included in rent or condominium fee. No charge or these fuels not used

    Why We Ask:

    We ask this question to help measure the overall cost of home ownership. Combined with income statistics, monthly ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

  4. IN THE PAST 12 MONTHS, did anyone in this household receive Food Stamps or a Food Stamp benefit card? Do NOT include WIC, the School Lunch Program, or assistance from food banks.
    1. Yes
    2. No

    Why We Ask:

    We ask this question to generate statistics used by federal, state, and local governments to monitor participation in food assistance programs. Non-profit organizations can use this information to plan and budget for food banks and food kitchens.

  5. Is this house, apartment, or mobile home part of a condominium?
    1. Yes - What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box. Monthly amount - Dollars $ .00 OR None
    2. No

    Why We Ask:

    We ask this question to help measure the overall cost of home ownership. Combined with income statistics, monthly ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

  6. Is this house, apartment, or mobile home -
    Mark (X) ONE box.
    1. Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
    2. Owned by you or someone in this household free and clear (without a mortgage or loan)?
    3. Rented?
    4. Occupied without payment of
      rent? ➔ SKIP to C

    Why We Ask:

    We ask this question to generate statistics about local housing markets. The Federal Housing Authority uses this information to develop its home mortgage insurance program. Federal and local agencies use it to evaluate the overall health of local housing markets, and to administer programs that help families afford good homes.


HOUSING (continued): Page 7

    B. Answer questions 18a and b if this house, apartment, or mobile home is RENTED. Otherwise, SKIP to question 19.

  1. a. What is the monthly rent for this house, apartment, or mobile home?
    Monthly amount - Dollars $ .00     b. Does the monthly rent include any meals?
    1. Yes
    2. No

    Why We Ask:

    We ask this question to determine the cost of shelter, a key economic measure. The federal government uses this information to develop fair market rents, which serve as the basis of Section 8 housing assistance. When combined with income, shelter costs help measure housing affordability in communities.

    2. C. Answer questions 16 - 20 if you or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to E on the next page.

  2. About how much do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale?
    Monthly amount - Dollars $ .00

    Why We Ask:

    We ask this question to get estimates of home values, regardless of whether homes are not currently for sale or have recently been sold. This information is used as an independent check on the appraised values of homes to see if the amounts financed for mortgages are reasonable.

  3. What are the annual real estate taxes on THIS property?
    1. Annual amount - Dollars $ .00
    2. None

    Why We Ask:

    We ask these questions to help measure the overall cost of home ownership. Combined with income statistics, ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

  4. What is the annual payment for fire, hazard, and flood insurance on THIS property?
    1. Annual amount - Dollars $ .00
    2. None

    Why We Ask:

    We ask these questions to help measure the overall cost of home ownership. Combined with income statistics, ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

  5. a. Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?
    1. Yes, mortgage, deed of trust, or similar debt
    2. Yes, contract to purchase
    3. No ➔ SKIP to question 23a
     b. How much is the regular monthly mortgage payment on THIS property? Include payment only on FIRST mortgage or contract to purchase
    1. Monthly amount - Dollars $ .00
    2. No regular payment required ➔ SKIP to question 20a
     c. Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?
    1. Yes, taxes included in mortgage payment
    2. No, taxes paid separately or taxes not required
     d. Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?
    1. Yes, insurance included in mortgage payment
    2. No, insurance paid separately or no Insurance

    Why We Ask:

    We ask these questions to help measure the overall cost of home ownership. Combined with income statistics, monthly ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

  6. a. Do you or any member of this household have a second mortgage or a home equity loan on THIS property?
    1. Yes, home equity loan
    2. Yes, second mortgage
    3. Yes, second mortgage and home equity loan
    4. No ➔ SKIP to D
     b. How much is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property?
    1. Monthly amount - Dollars $ .00
    2. No regular payment required

    Why We Ask:

    We ask these questions to help measure the overall cost of home ownership. Combined with income statistics, monthly ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

    7. D. Answer questions 16 - 20 if you or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to E on the next page.

  7. What are the total annual costs for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site?
    Exclude real estate taxes.
    1. Annual costs - Dollars $ .00

    Why We Ask:

    We ask these questions to help measure the overall cost of home ownership. Combined with income statistics, ownership costs offer an excellent measure of home affordability. Federal agencies use this information to assess the need for grants and housing assistance for elderly and low income homeowners.

    E. Answer questions about PERSON 1 on the next page if you listed at least one person on page 2. Otherwise, SKIP to page 28 for the mailing instructions.


PERSON 1: Page 8

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

    Why We Ask:

    We use this information to make sure responses to the survey are complete. We may follow-up to ask about incomplete or missing information on the form.

  2. Where was this person born?
    1. In the United States - Print name of state.
    2. Outside the United States - Print name of foreign country, or Puerto Rico, Guam, etc.

    Why We Ask:

    We ask these questions to get basic information about immigration and citizenship. The estimates help the Federal Government evaluate immigration and citizenship policy and develop programs for refugees and other foreign-born individuals.

  3. Is this person a citizen of the United States?
    1. Yes, born in the United States ➔ SKIP to 10a
    2. Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas
    3. Yes, born abroad of U.S. citizen parent or parents
    4. Yes, U.S. citizen by naturalization - Print year of naturalization
    5. No, not a U.S. citizen

    Why We Ask:

    We ask these questions to get basic information about immigration and citizenship. The estimates help the Federal Government evaluate immigration and citizenship policy and develop programs for refugees and other foreign-born individuals.

  4. When did this person come to live in the United States?
    Print numbers in boxes.
    Year

    Why We Ask:

    We ask these questions to get basic information about immigration and citizenship. The estimates help the Federal Government evaluate immigration and citizenship policy and develop programs for refugees and other foreign-born individuals.

  5. a. At any time IN THE LAST 3 MONTHS, has this person attended school or college?
    Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.
    1. No, has not attended in the last 3 months ➔ SKIP to question 11
    2. Yes, public school, public college
    3. Yes, private school, private college, home school
     b. What grade or level was this person attending?
    Mark(X) ONE box.
    1. Nursery school, preschool
    2. Kindergarten
    3. Grade 1 through 12 - Specify grade 1 - 12
    4. College undergraduate years (freshman to senior)
    5. Graduate or professional school beyond a bachelor's degree (for example: MA or PhD program, or medical or law school)

    Why We Ask:

    We ask this question to measure the educational participation of school-age children and adults. The Federal Government uses school enrollment data to enforce laws against discrimination in education and to develop adult education and literacy programs.  Local school districts, colleges, and universities can use this information to plan for school growth and teacher recruitment.

  6. What is the highest degree or level of school this person has COMPLETED?
    Mark (X) ONE box. If currently enrolled, mark the previous grade or highest degree received.
    1. No schooling completed
    2. Nursery school
    3. Kindergarten
    4. Grade 1 through 11
    5. 12th grade - NO DIPLOMA
    6. Regular high school diploma
    7. GED or alternative credential
    8. Some college credit, but less than 1 year of college credit
    9. 1 or more years of college credit, no degree
    10. Associate's degree (for example: AA, AS)
    11. Bachelor's degree (for example: BA, BS)
    12. Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)
    13. Professional degree beyond a bachelor's degree (for example: MD, DDS, DVM, LLB, JD)
    14. Doctorate degree (for example: PhD, EdD)

    Why We Ask:

    We ask this question to measure the level of education. Based on that information, employers can look for a labor force with the skills needed to support their businesses, and school districts can receive funds for adult education and literacy programs.

    7. F. Answer question 12 if this person has a bachelor's degree or higher. Otherwise, SKIP to question 13.

  7. This question focuses on this person's BACHELOR'S DEGREE. Please print below the specific major(s) of any BACHELOR'S DEGREES this person has received.
    (For example: chemical engineering, elementary teacher education, organizational psychology)

    Why We Ask:

    We ask this question to get information about the kinds of college degrees obtained. Combining this information with statistics about jobs and income allows educators to assess how graduates in differing fields are doing in the job market. Students, parents, professional societies, and educators can use this information to be aware of educational trends Employers can use the field of degree statistics to find out if there are potential employees in an area with the training and education needed to support their businesses.

  8. What is this person's ancestry or ethnic origin?
    (For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

    Why We Ask:

    We ask this question to generate statistics about the ethnic origin of the population. Information on ancestry can be used by communities to gauge the needs for services that are tailored to different cultural or language needs.

  9. a. Does this person speak a language other than English at home?
    Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.
    1. Yes
    2. No ➔ SKIP to question 15a
     b. What is this language?
    For example: Korean, Italian, Spanish, Vietnamese    c. How well does this person speak English?
    Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.
    1. Very well
    2. Well
    3. Not well
    4. Not at all

    Why We Ask:

    We ask these questions to create statistics about the needs of people who may have difficulty speaking English. State & local educational agencies use this information to apply for grants to improve educational skills and provide job training to communities. Other agencies and organizations use these statistics to develop health care programs, voting materials, and other services tailored to the language and cultural diversity of the community.

  10. a. Did this person live in this house or apartment 1 year ago?
    1. Person is under 1 year old ➔ SKIP to question 16
    2. Yes, this house - SKIP to question 16
    3. No, outside the United States and Puerto Rico - Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then SKIP to question 16
    4. No, different house in the United States or Puerto Rico
     b. Where did this person live 1 year ago?
    1. Address (Number and street name)
    2. Name of city, town, or post office
    3. Name of U.S. county or municipio in Puerto Rico
    4. Name of U.S. state or Puerto Rico
    5. Zip Code

    Why We Ask:

    We ask these questions to see where people are moving to, and where they are moving from. This information is used to plan for programs dealing with housing, health care, and education. Combined with other information about age and sex, communities can use these statistics to make long term plans for housing, schools, and hospitals.


PERSON 1 (continued): Page 9

  1. 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.
    1. Insurance through a current or former employer or union (of this person or another family member)
    2. Insurance purchased directly from an insurance company (by this person or another family member)
    3. Medicare, for people 65 and older, or people with certain disabilities
    4. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
    5. TRICARE or other military health care
    6. VA (including those who have ever used or enrolled for VA health care)
    7. Indian Health Service
    8. Any other type of health insurance or health coverage plan - Specify

    Why We Ask:

    We ask this question in order to give federal, state, and local policy makers accurate information about the insured and uninsured. Planning and implementing public health insurance programs requires accurate state and local information on health insurance status. State and local governments can use these statistics to target outreach and enrollment efforts to for programs like Medicare, Medicaid and the State Children's Health Insurance Program. Measuring health insurance status also helps public health agencies plan to meet current and future health care needs.

  2. a. Is this person deaf or does he/she have serious difficulty hearing?
    1. Yes
    2. No
     b. Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?
    1. Yes
    2. No

    Why We Ask:

    We ask these questions to generate statistics about the number and percentage of people with a disability. This information is used by federal, state, county and local governments to assess the impact of policies intended to reduce discrimination and improve participation in community activities, including job training and health care programs. Local transit agencies, under the Americans with Disabilities Act, use the information to make sure public transportation services are as useful for those with disabilities as they are for everyone else.

    3. G. Answer question 18a - c if this person is 5 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.

  3. a. Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?
    1. Yes
    2. No
     b. Does this person have serious difficulty walking or climbing stairs?
    1. Yes
    2. No
    c. Does this person have difficulty dressing or bathing?
    1. Yes
    2. No

    Why We Ask:

    We ask these questions to generate statistics about the number and percentage of people with a disability. This information is used by federal, state, county and local governments to assess the impact of policies intended to reduce discrimination and improve participation in community activities, including job training and health care programs. Local transit agencies, under the Americans with Disabilities Act, use the information to make sure public transportation services are as useful for those with disabilities as they are for everyone else.

    4. H. Answer question 19 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.

  4. Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor's office or shopping?
    1. Yes
    2. No

    Why We Ask:

    We ask these questions to generate statistics about the number and percentage of people with a disability. This information is used by federal, state, county and local governments to assess the impact of policies intended to reduce discrimination and improve participation in community activities, including job training and health care programs. Local transit agencies, under the Americans with Disabilities Act, use the information to make sure public transportation services are as useful for those with disabilities as they are for everyone else.

  5. What is this person's marital status?
    1. Now married
    2. Widowed
    3. Divorced
    4. Separated
    5. Never married ➔ SKIP to I

    Why We Ask:

    We gather information about marital status to aid local governments in their planning for community development. Budgeting and resource planning for single parent households, the elderly widowed and recently divorced requires accurate statistics about families and households in the community.

  6. In the PAST 12 MONTHS did this person get -? Mark "Yes" or "No"
    1. Married?
    2. Widowed?
    3. Divorced?

    Why We Ask:

    We ask questions about marital history to help local, state, and national level policymakers understand changes in families and households and how those changes affect child care, child support enforcement, and social services programs. These statistics are also used to evaluate tax policies, grants and funding for programs such as Temporary Assistance for Needy Families (TANF), Medicare, and Medicaid and assessing the effect of grants under the Healthy Marriage program.

  7. How many times has this person been married?
    1. Once
    2. Two times
    3. Three or more times

    Why We Ask:

    We ask questions about marital history to help local, state, and national level policymakers understand changes in families and households and how those changes affect child care, child support enforcement, and social services programs. These statistics are also used to evaluate tax policies, grants and funding for programs such as Temporary Assistance for Needy Families (TANF), Medicare, and Medicaid and assessing the effect of grants under the Healthy Marriage program.

  8. In what year did this person last get married?
    Year

    Why We Ask:

    We ask questions about marital history to help local, state, and national level policymakers understand changes in families and households and how those changes affect child care, child support enforcement, and social services programs. These statistics are also used to evaluate tax policies, grants and funding for programs such as Temporary Assistance for Needy Families (TANF), Medicare, and Medicaid and assessing the effect of grants under the Healthy Marriage program.

    9. I. Answer question 24 if this person is female and 15 - 50 years old. Otherwise, SKIP to question 25a.

  9. Has this person given birth to any children in the past 12 months?
    1. Yes
    2. No

    Why We Ask:

    We ask this question to get a measure of fertility, a basic planning tool needed for government and other agencies. Statistics about the number of babies born help federal, state, and local governments gauge the need for postpartum care, child welfare, and family planning services.

  10. a. Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?
    1. Yes
    2. No ➔ SKIP to question 26
     b. Is this grandparent currently responsible for most of the basic needs of any grandchildren under the age of 18 who live(s) in this house or apartment?
    1. Yes
    2. No ➔ SKIP to question 26
    c. How long has this grandparent been responsible for these grandchildren?
    If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time.
    1. Less than 6 months
    2. 6 to 11 months
    3. 1 or 2 years
    4. 3 or 4 years
    5. 5 or more years

    Why We Ask:

    We ask this question to help communities get an accurate picture of the make-up of families. State and local governments and other non-profits use this information to plan, budget and pay benefits to families where grandparents are the primary caregivers. Businesses, such as daycare centers and real estate developers, use these statistics to develop new products and services for grandparent-led households.

  11. Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
    Mark (X) ONE box.
    1. Yes, now on active duty
    2. Yes, on active duty during the last 12 months, but not now
    3. Yes, on active duty in the past, but not during the last 12 months
    4. No, training for Reserves or National Guard only - SKIP to question 28a
    5. No, never served in the military - SKIP to question 29a

    Why We Ask:

    We ask questions about military service to measure the needs of veterans. Veteran status is used by state and local governments to budget and plan for medical services, nursing home care, and employment and job training for veterans. The Federal Government uses the estimates to plan for the needs of returning personnel and veterans' health care needs.

  12. When did this person serve on active duty in the U.S. Armed Forces?
    Mark (X) a box for EACH period in which this person served, even if just for part of the period.
    1. September 2001 or later
    2. August 1990 to August 2001 (including Persian Gulf War)
    3. September 1980 to July 1990
    4. May 1975 to August 1980
    5. Vietnam era (August 1964 to April 1975)
    6. March 1961 to July 1964
    7. February 1955 to February 1961
    8. Korean War (July 1950 to January 1955)
    9. World War II (December 1941 to December 1946)
    10. November 1941 or earlier

    Why We Ask:

    We ask questions about military service to measure the needs of veterans. Veteran status is used by state and local governments to budget and plan for medical services, nursing home care, and employment and job training for veterans. The Federal Government uses the estimates to plan for the needs of returning personnel and veterans' health care needs.

  13. a. Does this person have a VA service-connected disability rating?
    1. Yes (such as 0%, 10%, 20%, ... , 100%)
    2. No ➔ SKIP to question 29a
     b. What is this person's service-connected disability rating?
    1. 0 percent
    2. 10 or 20 percent
    3. 30 or 40 percent
    4. 50 or 60 percent
    5. 70 percent or higher

    Why We Ask:

    We ask this question to help federal, state, and local governments measure the demand for health care services across the country. These statistics are necessary for budgeting and ensuring that appropriations are made to cover the expected cost of veterans' care.


PERSON 1 (continued): Page 10

  1. a. LAST WEEK, did this person work for pay at a job (or business)?
    1. Yes ➔ SKIP to question 30
    2. No - Did not work (or retired)
     b. LAST WEEK, did this person do ANY work for pay, even for as little as one hour?
    1. Yes
    2. No ➔ SKIP to question 35a

    Why We Ask:

    We ask these questions to generate an accurate picture of the U.S. labor market. Labor force information is used to allocate funds for programs that create new jobs in areas where jobs are most needed. These statistics are also used to enforce equal employment opportunity under the Civil Rights Act.

  2. At what location did this person work LAST WEEK? If this person worked at more than one location, print where he or she worked most last week.
    1. Address (Number and street name)
      If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection.
    2. Name of city, town, or post office
    3. Is the work location inside the limits of that city or town?
      • Yes
      • No, outside the city/town limits
    4. Name of county
    5. Name of U.S. state or foreign country
    6. ZIP Code

    Why We Ask:

    We ask this question to get a measure of fertility, a basic planning tool needed for government and other agencies. Statistics about the number of babies born help federal, state, and local governments gauge the need for postpartum care, child welfare, and family planning services.

  3. How did this person usually get to work LAST WEEK? If this person usually used more than one method of transportation during the trip, mark (X) the box of the one used for most of the distance.
    1. Car, truck, or van
    2. Bus or trolley bus
    3. Streetcar or trolley car
    4. Subway or elevated
    5. Railroad
    6. Ferryboat
    7. Taxicab
    8. Motorcycle
    9. Bicycle
    10. Walked
    11. Worked at home ➔ SKIP to Railroad question 39a
    12. Other method

    Why We Ask:

    We ask these questions to generate basic information about commuting patterns. The statistics are used by metropolitan planning organizations to design programs that ease traffic problems, reduce congestion and promote car pooling. Public transit agencies use the statistics to identify areas that need transit service, and police and fire departments use the statistics to plan for emergency services in areas where many people work.

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

  4. How many people, including this person, usually rode to work in the car, truck, or van LAST WEEK?
    Person(s)

    Why We Ask:

    We ask these questions to generate basic information about commuting patterns. The statistics are used by metropolitan planning organizations to design programs that ease traffic problems, reduce congestion and promote car pooling. Public transit agencies use the statistics to identify areas that need transit service, and police and fire departments use the statistics to plan for emergency services in areas where many people work.

  5. What time did this person usually leave home to go to work LAST WEEK?
    Hour Minute a.m. p.m

    Why We Ask:

    We ask these questions to generate basic information about commuting patterns. The statistics are used by metropolitan planning organizations to design programs that ease traffic problems, reduce congestion and promote car pooling. Public transit agencies use the statistics to identify areas that need transit service, and police and fire departments use the statistics to plan for emergency services in areas where many people work.

  6. How many minutes did it usually take this person to get from home to work LAST WEEK?
    Minutes

    Why We Ask:

    We ask these questions to generate basic information about commuting patterns. The statistics are used by metropolitan planning organizations to design programs that ease traffic problems, reduce congestion and promote car pooling. Public transit agencies use the statistics to identify areas that need transit service, and police and fire departments use the statistics to plan for emergency services in areas where many people work.

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

  7. a. LAST WEEK, was this person on layoff from a job?
    1. Yes ➔ SKIP to question 35c
    2. No
     b. LAST WEEK, was this person TEMPORARILY absent from a job or business?
    1. Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. - SKIP to question 38
    2. 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?
    1. Yes ➔ SKIP to question 37
    2. No

    Why We Ask:

    We ask these questions to generate an accurate picture of the U.S. labor market. Labor force information is used to allocate funds for programs that create new jobs in areas where jobs are most needed. These statistics are also used to enforce equal employment opportunity under the Civil Rights Act.

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

    Why We Ask:

    We ask these questions to generate an accurate picture of the U.S. labor market. Labor force information is used to allocate funds for programs that create new jobs in areas where jobs are most needed. These statistics are also used to enforce equal employment opportunity under the Civil Rights Act.

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

    Why We Ask:

    We ask these questions to generate an accurate picture of the U.S. labor market. Labor force information is used to allocate funds for programs that create new jobs in areas where jobs are most needed. These statistics are also used to enforce equal employment opportunity under the Civil Rights Act.

  10. When did this person last work, even for a few days?
    1. Within the past 12 months
    2. 1 to 5 years ago ➔ SKIP to L
    3. Over 5 years ago or never worked ➔ SKIP to question 47

    Why We Ask:

    We ask these questions to produce an accurate picture of work experience. The statistics are used to develop policies and programs that promote employment and career development and training, as well as to measure compliance with antidiscrimination laws. Businesses use information on last year's work status to decide where to locate new plants or offices. These statistics are also used to plan employment programs for seniors under the Older Americans Act.

  11. a. During the PAST 12 MONTHS (52 weeks), did this person work 50 or more weeks? Count paid time off as work.
    1. Yes ➔ SKIP to question 40
    2. No
     b. How many weeks DID this person work, even for a few hours, including paid vacation, paid
    sick leave, and military service?
    1. 50 to 52 weeks
    2. 48 to 49 weeks
    3. 40 to 47 weeks
    4. 27 to 39 weeks
    5. 14 to 26 weeks
    6. 13 weeks or less

    Why We Ask:

    We ask these questions to produce an accurate picture of work experience. The statistics are used to develop policies and programs that promote employment and career development and training, as well as to measure compliance with antidiscrimination laws. Businesses use information on last year's work status to decide where to locate new plants or offices. These statistics are also used to plan employment programs for seniors under the Older Americans Act.

  12. During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did this person usually work each WEEK?
    Usual hours worked each WEEK

    Why We Ask:

    We ask these questions to produce an accurate picture of work experience. The statistics are used to develop policies and programs that promote employment and career development and training, as well as to measure compliance with antidiscrimination laws. Businesses use information on last year's work status to decide where to locate new plants or offices. These statistics are also used to plan employment programs for seniors under the Older Americans Act.


PERSON 1 (continued): Page 11

    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.

  1. Was this person -
    Mark (X) ONE box.
    1. an employee of a PRIVATE FOR-PROFIT company or business, or of an individual, for wages, salary, or commissions?
    2. an employee of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or charitable organization?
    3. a local GOVERNMENT employee (city, county, etc.)?
    4. a state GOVERNMENT employee?
    5. a Federal GOVERNMENT employee?
    6. SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm?
    7. SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm?
    8. working WITHOUT PAY in family business or farm?

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  2. 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

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  3. 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)

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  4. Is this mainly -
    Mark (X) ONE box.
    1. manufacturing?
    2. wholesale trade?
    3. retail trade?
    4. other (agriculture, construction, service, government, etc.)?

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  5. What kind of work was this person doing?
    (For example: registered nurse, personnel manager, supervisor of order department, secretary, accountant)

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  6. 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)

    Why We Ask:

    We ask these questions to produce an accurate picture of the occupations and industries in which people work. The statistics are used to analyze employment trends and create career development programs. The statistics are also used to determine representation within employment categories in the enforcement of equal employment opportunity. Employers may also use information on industry, occupation, and class of worker to locate businesses near potential employees in specific fields.

  7. INCOME IN THE PAST 12 MONTHS
    Mark (X) the "Yes" box for each type of income this person received, and give your best estimate of the TOTAL AMOUNT during the PAST 12 MONTHS. (NOTE: The "past 12 months" is the period from today's date one year ago up through today.)

    Mark (X) the "No" box to show types of income NOT received.

    If net income was a loss, mark the "Loss" box to the right of the dollar amount.

    For income received jointly, report the appropriate share for each person - or, if that's not possible, report the whole amount for only one person and mark the "No" box for the other person.

    For income received jointly, report the appropriate share for each person - or, if that's not possible, report the whole amount for only one person and mark the "No" box for the other person.
    1. Wages, salary, commissions, bonuses, or tips from all jobs.
      Report amount before deductions for taxes, bonds, dues, or other items.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No
    2. Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships.
      Report NET income after business expenses.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months Loss
      2. No
    3. Interest, dividends, net rental income, royalty income, or income from estates and trusts.
      Report even small amounts credited to an account.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months Loss
      2. No
    4. Social Security or Railroad Retirement.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No
    5. Supplemental Security Income (SSI).
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No
    6. Any public assistance or welfare payments from the state or local welfare office.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No
    7. Retirement, survivor, or disability pensions.
      Do NOT include Social Security.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No
    8. Any other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony.
      Do NOT include lump sum payments such as money from an inheritance or the sale of a home.
      1. Yes ➔ $ .00 TOTAL AMOUNT for past 12 months
      2. No

    Why We Ask:

    We ask these questions to get key statistics used to determine poverty levels, measure economic well-being, and gauge the need for economic assistance. State and local governments use this information to decide how to allocate funds for food, health care, and other assistance programs.

  8. What was this person's total income during the PAST 12 MONTHS?
    Add entries in questions 47a to 47h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.
    1. None OR $ .00 TOTAL AMOUNT for past 12 months, LOSS

    Why We Ask:

    We ask these questions to get key statistics used to determine poverty levels, measure economic well-being, and gauge the need for economic assistance. State and local governments use this information to decide how to allocate funds for food, health care, and other assistance programs.

    9. ➔ 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.


PERSON 2: Page 12

The form is designed to gather information for up to five people living in the household. Pages 12-27 repeat the same detailed questions for each additional person that the person completing the form ("Person 1") filled out for him or herself on pages 8-11.

If there are more than five people in the household, their names should be listed on page 4 of the form. A Census Bureau representative will contact the number listed on page 1 to interview additional household members over the phone. Federal law protects the confidentiality of personal information, including names.

Mailing Instructions

Please make sure you have...

  • listed all and anamesnswered 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.

Thank you for your time and effort. It makes a difference!


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Source: U.S. Census Bureau | American Community Survey Office | Email ACS | Last Revised: May 09, 2013
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