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Appendix C 2011 American Community Survey: Group Quarters Questionnaire 117

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118 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13261011 U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration DC U.S. CENSUS BUREAU American Community Survey THE This booklet shows the content of the American Community Survey questionnaire. This questionnaire is available in either English or Spanish. Este cuestionario está disponible en español o en inglés. Para completar cuestionario en inglés, comience en To complete the English questionnaire, begin on la página 2. Para completar el cuestionario en page 2. To complete the Spanish questionnaire, flip español, vírelo y complete el lado verde. this over and complete the green side. Por favor, complete este cuestionario tan Please complete this form as soon as possible. pronto sea posible. Colóquelo en el sobre que se Place it in the envelope provided and HOLD it for a provee y GUÁRDELO hasta que un representante del census representative to return to pick it up. censo lo venga a recoger. If you need help or have questions about Si necesita ayuda o tiene preguntas sobre cómo completing this form, call the number that our completar este cuestionario, llame al número de census representative has given you. teléfono que le ha dado nuestro representante del censo. For more information about the American Para obtener más información sobre la Encuesta Community Survey, visit our web site at: sobre la Comunidad Estadounidense, vaya a nuestra http://www.census.gov/acs. página en la Internet: http://www.census.gov/acs. How was this form completed? CENSUS USE ONLY English Spanish OMB No. 0607-0810 ACS-1(GQ)(2011) FORM (09-08-2010) USCENSUSBUREAU §.;+,¤ 106

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119 APPENDIX C PREPUBLICATION COPY, UNCORRECTED PROOFS 13261029 1 What is your name? Please print your name. 5 7 Are you a citizen of the United States? What is your race? Mark (✗) one or more Include your telephone number, and today’s boxes. B date so we can contact you if there is a question. Yes, born in the United States ➔ SKIP to question 9a White Last Name Yes, born in Puerto Rico, Guam, the Black, African Am., or Negro U.S. Virgin Islands, or Northern Marianas American Indian or Alaska Native – Print Yes, born abroad of U.S. citizen parent or name of enrolled or principal tribe. parents First Name MI Yes, U.S. citizen by naturalization – Print year of naturalization Area Code + Number Asian Indian Native Hawaiian — No, not a U.S. citizen Chinese Guamanian or Chamorro Filipino Today’s Date Samoan 8 When did you come to live in the Month Day Year Japanese United States? Print numbers in boxes. Other Pacific Korean Islander – Print Year race, for example, Vietnamese Fijian, Tongan, and so on. Other Asian – Print race, 2 What is your sex? Mark (✗) ONE box. for example, Hmong, Laotian, Thai, Pakistani, Male Female Cambodian, and so on. 9 a. At any time IN THE LAST 3 MONTHS, have you attended school or college? Include only nursery or preschool, kindergarten, 3 What is your age and what is your date of elementary school, home school, and schooling birth? Please report babies as age 0 when the which leads to a high school diploma or a child is less than 1 year old. college degree. Print numbers in boxes. Some other race – Print race. No, have not attended in the last 3 Age (in years) Month Day Year of birth months ➔ SKIP to question 10 Yes, public school, public college Yes, private school, private college, home school A NOTE: Please answer BOTH Question 4 b. What grade or level were you attending? 6 Where were you born? about Hispanic origin and Question 5 Mark (✗) ONE box. about race. For this survey, Hispanic In the United States – Print name of state. origins are not races. Nursery school, preschool Kindergarten Grade 1 through 12 – Specify 4 Are you of Hispanic, Latino, or Spanish grade 1 - 12 origin? Outside the United States – Print name A of foreign country, or Puerto Rico, No, not of Hispanic, Latino, or Guam, etc. Spanish origin Yes, Mexican, Mexican Am., Chicano College undergraduate years (freshman to senior) Yes, Puerto Rican Graduate or professional school beyond Yes, Cuban a bachelor’s degree (for example: MA or PhD program, or medical or law school) Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. §.;+>¤ 2 107

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120 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13261037 10 What is the highest degree or level of 12 What is your ancestry or ethnic origin? 15 IN THE PAST 12 MONTHS, did you receive school you have COMPLETED? Mark (✗) Food Stamps or a Food Stamp benefit card? ONE box. If currently enrolled, mark the Include government benefits from the previous grade or highest degree received. Supplemental Nutrition Assistance Program (SNAP). Do NOT include WIC or the National C NO SCHOOLING COMPLETED School Lunch Program. (For example: Italian, Jamaican, African Am., No schooling completed Yes Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, NURSERY OR PRESCHOOL THROUGH GRADE 12 No Lebanese, Polish, Nigerian, Mexican, Taiwanese, Nursery school Ukrainian, and so on.) 16 Are you CURRENTLY covered by any of the 13 a. Do you speak a language other than Kindergarten following types of health insurance or English at home? health coverage plans? Mark "Yes" or "No" Grade 1 through 11 – Specify for EACH type of coverage in items a – h. grade 1 – 11 Yes Yes No a. Insurance through a current No ➔ SKIP to question 14a or former employer or union (of yours or another family b. What is this language? 12th grade – NO DIPLOMA member) b. Insurance purchased directly HIGH SCHOOL GRADUATE from an insurance company Regular high school diploma For example: Korean, Italian, Spanish, Vietnamese (by you or another family member) c. How well do you speak English? GED or alternative credential c. Medicare, for people 65 and Very well COLLEGE OR SOME COLLEGE older, or people with certain Well Some college credit, but less than 1 year of disabilities college credit Not well d. Medicaid, Medical Assistance, 1 or more years of college credit, no degree Not at all or any kind of government- Associate’s degree (for example: AA, AS) assistance plan for those with 14 a. Did you live at this address 1 year ago? low incomes or a disability Bachelor’s degree (for example: BA, BS) Person is under 1 year old ➔ SKIP to e. TRICARE or other AFTER BACHELOR’S DEGREE question 16 military health care Master’s degree (for example: MA, MS, Yes, at this address ➔ SKIP to MEng, MEd, MSW, MBA) question 15 f. VA (including if you have Professional degree beyond a bachelor’s ever used or enrolled for No, outside the United States and degree (for example: MD, DDS, DVM, LLB, VA health care) Puerto Rico – Print name of foreign JD) country, or U.S. Virgin Islands, Guam, Doctorate degree (for example: PhD, EdD) etc., below; then SKIP to question 15 g. Indian Health Service h. Any other type of health insurance or health coverage B No, at a different address in the plan – Specify Answer question 11 if you have a bachelor’s United States or Puerto Rico degree or higher. Otherwise, SKIP to question 12. b. Where did you live 1 year ago? Address (Number and street name) 11 This question focuses on your BACHELOR’S DEGREE. Please print below the specific major(s) of any BACHELOR’S DEGREES you have received. (For example: chemical Name of city, town, post office, military engineering, elementary teacher education, installation, or base organizational psychology) Name of U.S. county or municipio in Puerto Rico Name of U.S. state or Puerto Rico ZIP Code §.;+F¤ 3 108

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121 APPENDIX C PREPUBLICATION COPY, UNCORRECTED PROOFS 13261045 17 a. Are you deaf or do you have serious 20 What is your marital status? 26 Have you ever served on active duty in the difficulty hearing? U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include Now married training for the Reserves or National Guard, but Yes Widowed DOES include activation, for example, for the No Persian Gulf War. Divorced Separated Yes, now on active duty b. Are you blind or do you have serious Never married ➔ SKIP to E difficulty seeing even when wearing Yes, on active duty during the last 12 glasses? months, but not now 21 In the PAST 12 MONTHS did you get – Yes, on active duty in the past, but not Yes Yes No during the last 12 months No No, training for Reserves or National Guard a. Married? only ➔ SKIP to question 28a b. Widowed? No, never served in the military ➔ SKIP to C Answer question 18a – c if you are 5 years question 29a old or over. Otherwise, SKIP to I on page c. Divorced? 7 for further instructions; do not answer 22 How many times have you been married? any more questions. 27 When did you serve on active duty in the U.S. Armed Forces? Mark (✗) a box for EACH Once period in which you served, even if just for part Two times of the period. 18 a. Because of a physical, mental, or D emotional condition, do you have Three or more times September 2001 or later serious difficulty concentrating, remembering, or making decisions? August 1990 to August 2001 (including 23 In what year did you last get married? Persian Gulf War) Yes Year September 1980 to July 1990 No May 1975 to August 1980 Vietnam era (August 1964 to April 1975) b. Do you have serious difficulty walking E or climbing stairs? March 1961 to July 1964 Answer question 24 if you are female and 15 – 50 years old. Otherwise, SKIP to question Yes February 1955 to February 1961 25a. No Korean War (July 1950 to January 1955) January 1947 to June 1950 24 Have you given birth to any children in the c. Do you have difficulty dressing or past 12 months? World War II (December 1941 to bathing? December 1946) Yes Yes November 1941 or earlier No No 25 a. Do you have any of your own 28 a. Do you have a VA service-connected grandchildren under the age of 18 D disability rating? Answer question 19 if you are 15 years old living in this place? or over. Otherwise, SKIP to I on page 7 Yes (such as 0%, 10%, 20%, ... , 100%) for further instructions; do not answer any Yes more questions. No ➔ SKIP to question 29a No ➔ SKIP to question 26 b. What is your service-connected b. Are you currently responsible for most disability rating? of the basic needs of any grandchildren 19 Because of a physical, mental, or emotional under the age of 18 who lives in this condition, do you have difficulty doing 0 percent place? errands alone such as visiting a doctor’s office or shopping? 10 or 20 percent Yes 30 or 40 percent Yes No ➔ SKIP to question 26 50 or 60 percent No c. How long have you been responsible 70 percent or higher for these grandchildren? If you are financially responsible for more than one grandchild, answer the question for the grandchild for whom you have been responsible for the longest period of time. Less than 6 months 3 or 4 years 6 to 11 months 5 or more years 1 or 2 years §.;+N¤ 4 109

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122 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13261052 29 a. LAST WEEK, did you work for pay at a 36 During the LAST 4 WEEKS, have you been F Answer question 32 if you marked "Car, job (or business)? ACTIVELY looking for work? truck, or van" in question 31. Otherwise, SKIP to question 33. Yes Yes ➔ SKIP to question 30 No ➔ SKIP to question 38 No – Did not work (or retired) 32 How many people, including yourself, usually rode to work in the car, truck, or b. LAST WEEK, did you do ANY work for 37 LAST WEEK, could you have started a job if van LAST WEEK? pay, even for as little as one hour? offered one, or returned to work if recalled? Person(s) Yes Yes, could have gone to work No ➔ SKIP to question 35a No, because of own temporary illness No, because of all other reasons 30 At what location did you work LAST (in school, etc.) WEEK? If you worked at more than one 33 What time did you usually leave this location, print where you worked most address to go to work LAST WEEK? 38 When did you last work, even for a last week. few days? Hour Minute a. Address (Number and street name) a.m. : Within the past 12 months p.m. 1 to 5 years ago ➔ SKIP to H Over 5 years ago or never worked ➔ SKIP If the exact address is not known, give a description of the location such as the building 34 How many minutes did it usually take to question 47 you to get from this address to work name or the nearest street or intersection. LAST WEEK? 39 a. During the PAST 12 MONTHS (52 weeks), b. Name of city, town, post office, military did you work 50 or more weeks? Count Minutes installation, or base paid time off as work. Yes ➔ SKIP to question 40 No c. Is the work location inside the limits of G that city or town? Answer questions 35 – 38 if you did NOT b. How many weeks DID you work, even work last week. Otherwise, SKIP to question for a few hours, including paid vacation, Yes 39a. paid sick leave, and military service? No, outside the city/town limits 50 to 52 weeks d. Name of county 35 a. LAST WEEK, were you on layoff from 48 to 49 weeks a job? 40 to 47 weeks Yes ➔ SKIP to question 35c 27 to 39 weeks No 14 to 26 weeks e. Name of U.S. state or foreign country 13 weeks or less b. LAST WEEK, were you TEMPORARILY absent from a job or business? 40 During the PAST 12 MONTHS, in the WEEKS Yes, on vacation, temporary illness, WORKED, how many hours did you usually f. ZIP Code maternity leave, other family/personal work each WEEK? reasons, bad weather, etc. ➔ SKIP to Usual hours worked each WEEK question 38 No ➔ SKIP to question 36 31 How did you usually get to work LAST c. Have you been informed that you will be WEEK? If you usually used more than one recalled to work within the next 6 months method of transportation during the trip, OR been given a date to return to work? mark (✗) the box of the one used for most of the distance. E Yes ➔ SKIP to question 37 Car, truck, or van Motorcycle No Bus or trolley bus Bicycle Streetcar or Walked trolley car Worked at this Subway or elevated address ➔ SKIP to question 39a Railroad Other method Ferryboat Taxicab §.;+U¤ 5 110

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123 APPENDIX C PREPUBLICATION COPY, UNCORRECTED PROOFS 13261060 45 What kind of work were you doing? (For d. Did you receive any Social Security or H Answer questions 41 – 46 if you worked in Railroad Retirement income in the PAST example: registered nurse, personnel manager, the past 5 years. Otherwise, SKIP to 12 MONTHS? supervisor of order department, secretary, question 47. accountant) Yes ➔ What was the amount? Total amount - Dollars 41–46 CURRENT OR MOST RECENT JOB ACTIVITY Describe clearly your chief job activity or $ .00 business last week. If you had more than one , job, describe the one at which you worked the 46 What were your most important activities or duties? (For example: patient care, directing No most hours. If you did not have a job or hiring policies, supervising order clerks, typing business last week, give information for your e. Did you receive any Supplemental and filing, reconciling financial records) last job or business. Security Income (SSI) in the PAST 12 MONTHS? 41 Were you – F Mark (✗) ONE box. Yes ➔ What was the amount? Total amount - Dollars 47 INCOME IN THE PAST 12 MONTHS an employee of a PRIVATE FOR-PROFIT company or business, or of an individual, Mark (✗) the "Yes" box for each type of income $ .00 for wages, salary, or commissions? you received, and give your best estimate of the , an employee of a PRIVATE NOT-FOR-PROFIT, TOTAL AMOUNT during the PAST 12 MONTHS. No tax-exempt, or charitable organization? (NOTE: The "past 12 months" is the period from a local GOVERNMENT employee (city, today’s date one year ago up through today.) f. Did you receive any public assistance or county, etc.)? welfare payments from the state or local Mark (✗) the "No" box to show types of income a state GOVERNMENT employee? welfare office in the PAST 12 MONTHS? NOT received. If your net income was a loss, mark the "Loss" a Federal GOVERNMENT employee? Yes ➔ What was the amount? box to the right of the dollar amount. SELF-EMPLOYED in own NOT Total amount - Dollars For income received jointly, report only your INCORPORATED business, professional share of the amount received or earned. practice, or farm? $ .00 , SELF-EMPLOYED in own INCORPORATED a. Did you receive any wages, salary, business, professional practice, or farm? No commissions, bonuses, or tips in the PAST 12 MONTHS? working WITHOUT PAY in family business g. Did you receive any retirement, survivor, or farm? or disability pensions in the PAST 12 Yes ➔ What was the amount from MONTHS? Do NOT include Social Security. all jobs before deductions for 42 For whom did you work? taxes, bonds, dues, or other Yes ➔ What was the amount? If now on active duty in items? the Armed Forces, mark (✗) this box ➜ Total amount - Dollars Total amount - Dollars and print the branch of the Armed Forces. $ .00 Name of company, business, or other employer $ .00 , , No No h. Did you have any other sources of income b. Did you have any self-employment received regularly such as Veterans’ (VA) income from own nonfarm businesses 43 What kind of business or industry was this? payments, unemployment compensation, or farm businesses, including child support, or alimony in the PAST 12 Describe the activity at the location where proprietorships and partnerships, MONTHS? Do NOT include lump sum employed. (For example: hospital, newspaper in the PAST 12 MONTHS? publishing, mail order house, auto engine payments such as money from an inheritance manufacturing, bank) or sale of a home. Yes ➔ What was the net income after business expenses? Yes ➔ What was the amount? Total amount - Dollars Total amount - Dollars Loss $ .00 $ .00 , , 44 Is this mainly – Mark (✗) ONE box. No No manufacturing? c. Did you receive any interest, dividends, wholesale trade? net rental income, royalty income, or 48 What was your total income during the income from estates and trusts in the PAST 12 MONTHS? Add entries 47a–47h; retail trade? PAST 12 MONTHS? Report even small subtract any losses. If net income was a loss, other (agriculture, construction, service, amounts credited to an account. enter the amount and mark (✗) the "Loss" box government, etc.)? next to the dollar amount. Yes ➔ What was the amount? Total amount - Dollars Total amount - Dollars Loss Loss $ .00 $ .00 None , , , OR No §.;+]¤ 6 111

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124 SMALL POPULATIONS, LARGE EFFECTS PREPUBLICATION COPY, UNCORRECTED PROOFS 13261078 I Thank you very much for your participation. Place the questionnaire in the envelope and HOLD for your Census Bureau Representative to pick up. The Census Bureau estimates that this form will take about 25 minutes to complete, including the time for reviewing the instructions and answers. Send comments regarding this burden estimate, including suggestions for reducing this burden, to: Paperwork Reduction Project 0607-0810, U.S. Census Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may email comments to Paperwork@census.gov; use "Paperwork Project 0607-0810" as the subject. Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget. This 8-digit number appears in the bottom right on the front cover of this form. §.;+o¤ 7 112