Population 09

American Community Survey
Administrative Questions
for use in the ACS
form and return after receiving
StartQuestions as they appear in the questionnaire. Here
Please print todays date. Month Day Year
mation about g or staying at ng label and ment, or mobile dress on the
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
ave questions s form, please call elephone call is free.
(TDD): ne call is free.
abla espaol y cuestionario, 33-5625. stionario en por telfono paol.
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. Person 1 Number of people (Person 1 is the person living or staying here in whose name this house Fill apartment is owned, being bought, or rented. If there is no such or out pages 2, 3, and 4 for everyone, including yourself, who is living orstart with at this address adult living or staying here.)Then person, staying the name of any for more than 2 months. complete the rest of the form.
P
Last Name (Please print)
1 What is Person 2s name?
merican site at:
2 How is this person related

Husband or wife Biological son or daughter Adopted son or daughter
AU
FORM (05-22-2008)
ACS-1(2009)KFI
OMB No. 0607-0810
What is Person 1s name?

Last Name (Please print) First Name MI
Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law
se (Black)
ACS-1(2009)KFI, Page 1, Green Pantone 354 (20 and 40%) 2 How is this Source: ACS-1(2009)KFI person related to Person 1?
X
Person 1
What is Person 1s sex? Mark (X) ONE box. NEEDS MEETING FEDERAL
Male Female
3 What is Person 2s sex? Ma

Male
The Census Bureau uses this information to ensure response accuracy and completeness, 4 What is Person with incomplete or missing information. 4 What is Person 2s age and and for contacting respondents 1s age and what is Person 1s 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 Age (in years)
Femal
Please report babies as age 0 Print
Month
NOTE: Please answer BOTH Question 5 about Hispanic origin and 5

Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban
Question 6 about race. For this survey, Hispanic origins are not races.
NOTE: Please answer BO
Question 6 about race. For
5 Is Person 2 of Hispanic, La
No, not of Hispanic, Latino Yes, Puerto Rican Yes, Cuban
Yes, Mexican, Mexican Am

Population: Question on Relationship
1 What is Person 2s name?
13199021
Person 2
First Person 2Name
13199021
MI
1 ere in whose name this house ented. If there is no such ving or staying here.)
ere in whose name this house ented. If there is no such ving or staying here.)
MI
Question as it appears in the questionnaire. 1 What is Person 2s name? First Mark How is this person related to Person 1? Name (X) ONE box. 2 Last Name (Please print)
Husband or wife Biological son or daughter Adopted son or daughter Husband or wife Stepson or stepdaughter Biological son or daughter Brother or sister Adopted son or daughter Father or mother Stepson or stepdaughter Grandchild Brother or sister Parent-in-law Father or mother Grandchild Male Parent-in-law
MI
Son-in-law or daughter-in-law Other relative Roomer or boarder Son-in-law or daughter-in-law Housemate or roommate Other relative Unmarried partner Roomer or boarder Foster child Housemate or roommate Other nonrelative Unmarried partner Foster child Other nonrelative
2 How is this person related to Person 1? Mark (X) ONE box.
st Name
1?
st Name
MI
ox. 1?
Source: ACS-1(2009)KFI 3 What is Person
2s sex? Mark (X) ONE box.

Female
rson 1s date of birth? 4 What is Person 2s sex?andFEDERAL NEEDS of birth? MEETING what is Person ox. 3 What is Person 2s age Mark (X) ONE box. 2s date ild is less than 1 year old. Please report babies as age 0 when the child is less than 1 year old. Male Female boxes. The census subject about relationship Print numbersforboxes. is essential in classifying the population into families
Age (in years) Month Day Year of birth
rson 1s date of and other groups. Information about changes in is Person 2s date of the American family, birth? 4 What is Person 2s age and what the composition of birth? ild is less than 1 year old. number Please report babies as age 0the number of children living old. only one parent, from the of people living alone to when the child is less than 1 year with boxes. Print number of federal programs. In federally funded is essential for planning and carrying out anumbers in boxes.
ear of birth
ear of birth Age (in programs, how the money Month Questionspent hinges, at originpartially, on nutrition and educationyears) 5 about Hispanic origin and 5 about Hispanic least and NOTE: Please answer BOTH Day isYear of birth , Hispanic origins are not races. Questiondata about relationship. 6 about race. For this survey, Hispanic origins are not races. decennial census program
nish origin?
, Hispanic origins are not races.
5 about Hispanic origin and rigin
5 Is Person 2 of Hispanic, Latino, or Spanish origin? NOTE: not of Hispanic, Latino, or Question 5 about Hispanic origin and No, Please answer BOTH Spanish origin 5 Is Person 2 of Hispanic, Latino, or Spanish origin?
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican No, not of Hispanic, Latino, or Spanish origin Yes, Cuban Yes, Mexican, Mexican Am., Chicano Yes, another Hispanic, Latino, or Spanish origin Print origin, for example, Yes, Puerto Rican Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. Education Yes, Cuban
nish origin?
rigin
origin Print origin, for example, araguan, Salvadoran, Spaniard,
COMMUNITY BENEFITS
Government
or more boxes.
Federal Data about relationship are used to Yes, another Hispanic, Latino, or Spanish origin Print origin, for example, origin Print origin, for example, agencies use data about relaArgentinean, Colombian, Nicaraguan, Salvadoran, Spaniard, araguan, Salvadoran, Spaniard, tionship for a variety of programmaticDominican,allocate funds to states and counties and so on.
Black, African Am., or Negro
to purposes. 6 What is Person 2s race? Mark (X) one or more boxes. improve the education of children in lowincome families. White
or more boxes.
Housing 6 What is Person 2s race? Mark (X) one or more boxes. t name of enrolled or principal tribe. American Indian or Alaska Native Print name of enrolled or principal tribe. Social Services White Data about families in poverty are used to distribute funds for housing toor Negro Local health agencies plan and administer Black, African Am., local governments. programs promoting the well-being of t name of enrolled or principal tribe. American Indian or Alaska Native Print name of enrolled or principal tribe. Japanese Asian Indian Native Hawaiian Native Hawaiian families and children using information on relationship. Korean Chinese Guamanian or Chamorro Guamanian or Chamorro
Samoan Native Hawaiian Other Pacific Islander Guamanian orexample, Print race, for Chamorro Fijian, Tongan, and Samoan so on. Other Pacific Islander Print race, for example, Fijian, Tongan, and so on. Filipino Asian Indian Other Asian Print race, Chinese for example, Hmong, Laotian, Thai, Pakistani, Filipino Cambodian, and so on. Other Asian Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Some other race Print race. Vietnamese Japanese Korean Vietnamese Samoan www.census.gov Native Hawaiian Other Pacific Islander Guamanian orexample, Print race, for Chamorro Fijian, Tongan, and Samoan so on. Other Pacific Islander Print race, for example, Fijian, Tongan, and so on.
se
se
Some other race Print race.
2 How is this per
Husband or w

1
Biological so First Name MI
Adopted son
Population: Question on Sex
Stepson or s
Brother or si Grandchild
2 How is this person related to Person 1? Question as it1 appears in the questionnaire. X Person 3
What is Person 1s sex? Mark (X) ONE box.
Male
Source: ACS-1(2009)KFI 4 What is Person
Father or mo
Parent-in-law
3 What is Person
Male
Female
1s age and what is Person 1s 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 Year MEETING FEDERAL Day NEEDS of birth
4 What is Person
Age (in years)
Please report bab
Census data about sex are critical because so many federal programs must differentiate between males and females. NOTE: Please answer BOTH Question 5 about Hispanic origin and The U.S. Departments of Education and Health and Human NOTE: Please Question these race. For this implement, and evaluate various Question 6 abo Services are required by statute to use6 aboutdata to fund, survey, Hispanic origins are not races. social and welfare programs, such as 1 of Special Supplemental Food Program for Women, 5 Is Person the Hispanic, Latino, or Spanish origin? 5 Is Person 2 of H Infants, and Children (WIC) or the Low-Income Home Energy Assistance Program (LIHEAP). Laws No, not of H No, not of Hispanic, Latino, or Spanish origin to promote equal employment opportunity for women also require census data on sex. The Yes, Mexican Yes, Mexican, Mexican Am., Chicano U.S. Department of Veterans Affairs must use census data to develop its state projections of Yes, Puerto R veterans facilities and benefits. Yes, Puerto Rican
Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. Yes, Cuban
Yes, another Argentinean, and so on.
COMMUNITY BENEFITS
Planning
6
What is Person 1s race? Mark (X) one or more boxes.
White
Education
6 What is Person
White
State and local planners analyze social Am., or Negro about sex are used to allocate Data Black, African and economic characteristics of males funds to institutions of higher learning American Indian or Alaska Native Print name of enrolled or principal tribe. and females to predict future needs for that increase participation, particularly housing, education, childcare, health care, of minority women, in scientific and transportation, and employment. engineering programs under the Higher Education Act. Asian Indian Japanese Native Hawaiian Employment
Chinese Filipino Korean Guamanian or Chamorro Samoan
Black, African
American Ind
Asian Indian Chinese Filipino
Data about sex are used to evaluate Other Asian Print race, Other Pacific Islander employment practices under for example, Hmong, At the state and county levels, data about the Civil Print race, for example, Laotian, Thai, Pakistani, Fijian, Tongan, and Rights Act. sex are used to allocate funds for food, Cambodian, and so on. so on. health care services, and classes in meal The Equal Employment Opportunity planning to low-income women with Commission, using data about sex, children. establishes and evaluates guidelines dealing with equal employment opportunity.
Social Vietnamese Services
Other Asian for example, Laotian, Thai Cambodian,
Some other r
Housing Data about sex are used to evaluate Civil Rights Act.
.4{6 policies and practices under the housing

www.census.gov
ACS-1(2009)KFI, Page 2, Base (Black)
ACS-1(2009)KFI, Page 2, G
Biological son or daugh

Last Name (Please print) First Name MI
Adopted son or daught Brother or sister Father or mother Grandchild Parent-in-law
Stepson or stepdaught

2 How is this person related to Person 1? Population: Question on Age
X
Person 1
3 4
What is Person 1s sex? Mark (X) ONE box.
Question as it Female appears in the questionnaire. Male
3 What is Person 2s sex?

Male
Fe
What is Person 1s age and what is Person 1s 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
4 What is Person 2s age a

Age (in years)
Please report babies as ag Pr
Source: ACS-1(2009)KFI 6 Question
NOTE: Please answer BOTH Question 5 about Hispanic origin and

No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano
about race. For this survey, Hispanic origins are not races.
NOTE: Please answer
Question 6 about race.
5 Is Person 2 of Hispanic,
MEETING FEDERAL NEEDS
No, not of Hispanic, La
Yes, Mexican, Mexican
Age is central for any number of federal programs that target funds or services to children, Yes, Puerto Rican Yes, Puerto Rican working-age adults, women of childbearing age, or the older population. The U.S. Department Yes, Cuban Yes, Cuban of Education uses census age data in its formula for allotment to states. Under the Voting Yes, another Hispanic, Latino, or are required for origin, for example, Rights Act, these data on population of voting ageSpanish origin Print legislative redistricting. Yes, another Hispanic, Argentinean, Colombia Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, The U.S. Department of Veterans Affairs uses age to develop its mandated state projections on so on. and and so on. the need for hospitals, nursing homes, cemeteries, domiciliary services, and other benefits for veterans.
6
White Black, African Am., or Negro White
6 What is Person 2s race
COMMUNITY Print name of American Indian or Alaska NativeBENEFITS enrolled or principal tribe.
Education
Asian Indian Counties and school districts are allotted funds based on age data. These funds Chinese provide resources and services to Filipino improve the education of economically Other Asian Print race, disadvantaged children example, Hmong, for and children with Laotian, Thai, Pakistani, disabilities.
Black, African Am., or N
American Indian or Ala
health services, and retirement homes by using age data. Japanese Native Hawaiian
Korean Guamanian or Chamorro Vietnamese Employment Samoan Other used Islander Data about age are Pacific to target Print race, for example, for job training programs. and Fijian, Tongan, so on.
Asian Indian Chinese Filipino
veterans
Locations where new schools are needed, as well as the required grade levels (elementary, middle, or high school) are identified using data Some other race Print race. about age. Government
Cambodian, and so on.
Equal employment opportunities are enforced using data about age. Social Services Age data are used to forecast the number of people eligible for Social Security and Medicare benefits.
Other Asian Print race for example, Hmong, Laotian, Thai, Pakistani Cambodian, and so on.
Some other race Prin
Data presenting the voting-age population are used by states to meet legislative Under the Older Americans Act, age data redistricting requirements. are part of ACS-1(2009)KFI, Page 2, Base (Black) the formula used to allocate ACS-1(2009)KFI, Page 2, Green Pa funds for services to seniors with low Planners at all levels of government incomes. forecast the need for highways, hospitals,
.4{6
www.census.gov
3 4 4

5 5
Population:Age (in years) Question on Hispanic Origin birth Month Day Year of
What is Person 1s sex?and whatONE box. 1s date of birth? What is Person 1s age Mark (X) is Person Please report babies as age 0 when the child is less than 1 year old. Male Female Print numbers in boxes. What years) Age (inis Person 1s age and what is Person 1s date of birth? Month Day Year of birth Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes.
3 What is Person 2s sex?and 4 What is Person 2s age Ma 4
Please report babies as age 0 Male Fema Print What years) Age (inis Person 2s age and Month Please report babies as age 0 Print
Age (in years)
NOTE: Please answer BOTH Question 5 about Hispanic origin and

Yes, Mexican, Mexican Latino, or Is Person 1 of Hispanic, Am., ChicanoSpanish origin? Yes, not of Hispanic, Latino, or Spanish origin No, Puerto Rican Cuban Yes, Mexican, Mexican Am., Chicano
NOTE: Please answer BO 5
Month
Question 6 about race. For
Please answer BOTH Question NOTE: Question as it appears in the 5 about Hispanic origin and No, not of Hispanic, Latino, or Spanish origin Question 6 about race. For this survey, questionnaire. are not races. Hispanic origins
NOTE: Please answer BO
Is Person 2 of Hispanic, La
No, not of Hispanic, Latino Question 6 about race. For
Yes, Mexican, Mexican La 5 Is Person 2 of Hispanic, Am
Yes, not of Hispanic, Latino No, Puerto Rican
Cuban Yes, Mexican, Mexican Am
another Hispanic, Latino, or Spanish origin Print origin, for example, Yes, Puerto Rican Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, Yes, so on. and Cuban Yes, another Hispanic, Latino, or Spanish origin Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.
another Hispanic, Lati Yes, Puerto Rican Argentinean, Colombian, D Yes, so on. and Cuban

White
6 What is Person 2s race? M

White
Yes, another Hispanic, Lati Argentinean, Colombian, D and so on.
Black, African Am., or Negro 6 ACS-1(2009)KFI Source:What is Person 1s race? Mark (X) one or more boxes. American Indian or Alaska Native Print name of enrolled or principal tribe. White Black, African Am., or Negro American Indian or Alaska Native Print name of enrolled or principal tribe.
Black, African Am., or Neg 6 What is Person 2s race? M
American Indian or Alaska White
Black, African Am., or Neg
American Indian or Alaska
Asian Indian Asian Native Hawaiian Hispanic origin is used in numerous programsJapanesevital in making policy decisions. These Indian and is data are needed to determine compliance withKorean provisions of antidiscrimination in employment Chinese Chinese Guamanian or Chamorro and minority recruitment legislation. Under the Voting Rights Act, data about Hispanic origin Indian Filipino Vietnamese Filipino Samoan Asian Indian Japanese Asian Native Hawaiian are essential to ensure enforcement of bilingual election rules. Hispanic origin classifications Other Asian Print race, Other Pacific Islander Other Asian Print race, Chinese Korean Guamanian or Chamorro used by the Census Bureau and Hmong,federal agencies meet the requirements of standardsChinese for example, other Print race, for example, for example, Hmong, Filipino Thai, Pakistani, Vietnamese Filipino Thai, Pakistani, Samoan the Standards for the Laotian, Fijian, to Laotian, issued by the Office of Management and Budget in 1997 (RevisionsTongan, and Cambodian, and so on. so on. Cambodian, and so on. Classification of Federal Data on Print race, Ethnicity). These standards set forthguidance for Other Asian Race and Other Pacific Islander Other Asian Print race, for reporting on for example, Hmong, statistical collection and example, Hmong,race and ethnicity used Printall federal agencies. by race, for example, Laotian, Thai, Pakistani, Fijian, Tongan, and Laotian, Thai, Pakistani, Cambodian, and so on. Some other race Print race. so on.
Cambodian, and so on. Some other race Print rac
Some other race Print rac
2
Social Services
COMMUNITY .4{6 BENEFITS

Employment
.4{6 Data about Hispanic origin are used to Page 2, Green Pant ACS-1(2009)KFI, Act, ACS-1(2009)KFI, Under the Public Health ServicePage 2, Base (Black)
2
Hispanic origin is one of the factors used monitor and enforce equal employment in identifying segments of the population opportunities under the Civil Rights Act. ACS-1(2009)KFI, Page 2, Base (Black) ACS-1(2009)KFI, Page 2, Green Pant who may not be getting needed medical services. Government The Voting Rights Act ensures equality in voting. Compliance of local jurisdictions is monitored using counts of the voting-age population by national origin.
www.census.gov
6 5
What is Person 1s race? Mark (X) one or more boxes. Is Person 1 of Hispanic, Latino, or Spanish origin?
White No, not of Hispanic, Latino, or Spanish origin Black, African Mexican Am., Yes, Mexican, Am., or Negro Chicano American Indian or Alaska Native Print name of enrolled or principal tribe. Yes, Puerto Rican Yes, another Hispanic, Latino, or Spanish origin Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, Asian Indian Japanese Native Hawaiian and so on. Chinese Korean Guamanian or Chamorro
6 What is Person 2s race? Mark (X) 5 Is Person 2 of Hispanic, Latino, o
White No, not of Hispanic, Latino, or Spa American Indian or Alaska Native Yes, Puerto Rican Yes, Cuban
Black, African Mexican Am., Yes, Mexican, Am., or Negro Chica
American Community Survey Yes, Cuban

Population: Question on Race
Question as it appearsVietnamese in the questionnaire. Filipino Samoan

6
for example, Hmong, White Thai, Pakistani, Laotian, Cambodian, and so on. Black, African Am., or Negro
Yes, another Hispanic, Latino, or S Argentinean, Colombian, Dominica Jap Asian Indian and so on. Ko Chinese Filipino for example, Hmong, White Thai, Pakistani, Laotian, Cambodian, and so on. Black, African Am., or Negro
Vie
Other Asian Print race, Other What is Person1s race? Mark (X) one or more boxes. Pacific Islander
Print race, for example, Fijian, Tongan, and so on.
Other Asian Print race, 6 What is Person2s race? Mark (X)
American Indian or Alaska Native Print name of enrolled or principal tribe. Some other race Print race. Asian Indian Japanese Korean Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Print race, for example, Fijian, Tongan, and ACS-1(2009)KFI, so on.
American Indian or Alaska Native Some other race Print race. Asian Indian Chinese Filipino
Jap
Chinese Filipino
.4{6 Vietnamese
Base (Black)
Ko
Vie
Other Asian Print race, for example, Hmong, Laotian, Thai, Pakistani, ACS-1(2009)KFI, Page 2, Cambodian, and so on.
Other Asian Print race, for example, Hmong, Laotian, Thai, Pakistani, Page 2, Green Pantone Cambodian, and so on.
Source: ACS-1(2009)KFI
.4{6
Race is key to implementing any number of federal laws and is a critical factor in the basic 2, Green Pantone 3 ACS-1(2009)KFI, Page 2, Base (Black) ACS-1(2009)KFI, Page research behind numerous policies. Race data are required by federal programs promoting equal employment opportunity and are needed to assess racial disparities in health and access to care, among other uses. Racial classifications used by the Census Bureau and other federal agencies meet the requirements of standards issued by the Office of Management and Budget in 1997 (Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity). These standards set forth guidance for statistical collection and reporting on race and ethnicity used by all federal agencies.
COMMUNITY BENEFITS
Education Under Title 20, race is used as part of the formula to fund programs that foster equal opportunity through postsecondary education for African Americans. This is achieved by funding programs at historically Black colleges and universities in professional and academic areas where African Americans are underrepresented in society. Employment Race, under the Civil Rights Act, is used to assess fairness of employment practices. Social Services For the Public Health Service Act, race is a key factor in identifying segments of the population who may not be receiving needed medical services. Government States require data about the racial makeup of the voting-age population to meet legislative redistricting requirements. Data about race are needed to monitor compliance with the Voting Rights Act by local jurisdictions.
www.census.gov
American Community Survey Person 1

Last Name Question on Year of Entry
Population: Question on Place of Birth Please Question on Citizenship copy the name of Person 1 from page 2,
then continue answering questions below.
11 What is the highest degree or level of sch
this person has COMPLETED? Mark (X) ON If currently enrolled, mark the previous grade highest degree received.
NO SCHOOLING COMPLETED
No schooling completed MI Nursery school Kindergarten Grade 1 through 11 Specify grade 1 11
NURSERY OR PRESCHOOL THROUGH GRAD
First Name
Questions as they appear in the questionnaire.

7
Where was this person born? In the United States Print name of state.
Outside the United States Print name of foreign country, or Puerto Rico, Guam, etc.
12th grade NO DIPLOMA

HIGH SCHOOL GRADUATE
Regular high school diploma GED or alternative credential

COLLEGE OR SOME COLLEGE
Is this person a citizen of the United States? Yes, born in the United States SKIP to 10a Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas Yes, born abroad of U.S. citizen parent or parents Yes, U.S. citizen by naturalization Print year of naturalization
Some college credit, but less than 1 yea college credit
1 or more years of college credit, no deg
Associates degree (for example: AA, AS

AFTER BACHELORS DEGREE
Bachelors degree (for example: BA, BS
No, not a U.S. citizen
Masters degree (for example: MA, MS, MEd, MSW, MBA) Professional degree beyond a bachelor (for example: MD, DDS, DVM, LLB, JD)
When did this person come to live in the United States? Print numbers in boxes. Year
Doctorate degree (for example: PhD, Ed
F
10 ACS-1(2009)KFI Source: 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.
Answer question 12 if this person has a bachelors degree or higher. Otherwise, SKIP to question 13.
BACHELORS DEGREE. Please print below specific major(s) of any BACHELORS DEG These questions provide essential data for setting and evaluating immigration policieshas received. (For example: che this person and Yes, public school, public college engineering, elementary laws. Knowing the characteristics of immigrants helps legislators and others understand how teacher education, Yes, private school, private college, organizational psychology) different immigrant groups are assimilated. Federal agencies require these data to develop home school programs for refugees and otherWhat grade or level was this person attending? b. foreign-born individuals. Vital information on lifetime Mark (X) ONE box. migration among states also comes from the place of birth question. months SKIP to question 11 Nursery school, preschool Kindergarten Grade 1 through 12 Specify grade 1 12
MEETING not attended in theNEEDS FEDERAL last 3 No, has
12 This question focuses on this persons
College undergraduate years (freshman to senior) Graduate or professional school beyond a bachelors degree (for example: MA or PhD program, or medical or law school)
.4{y

Population: Question on Place of Birth Question on Citizenship Question on Year of Entry
COMMUNITY BENEFITS
Education Data are used to allocate funds to public and private nonprofit organizations to provide employment resources aimed at making the foreign-born economically self-sufficient. Social Services These data are used, in conjunction with the Public Health Service Act, to assist states and local agencies with developing health care and other services tailored to the language and cultural diversity of the foreign-born. Government The U.S. Department of Homeland Security uses citizenship data to project staffing and other resource needs to complete the naturalization process for noncitizens. Under the Voting Rights Act, these data are required to evaluate voting practices of governmental subdivisions (e.g., states, counties, and school districts). Employment Data about place of birth and citizenship are used to evaluate the effectiveness of equal employment opportunity policies and programs under the Civil Rights Act.
www.census.gov
Not at all to then SKIP Bachelors degree (for example: BA, BS) 13 What is this highest degree or Answer question 12 if this person has of F 11 What is the has COMPLETED? level a(X)school a. Did this personpl Yes, U.S. citizen by naturalization Print year Mark this person AFTER BACHELORS or higher. Otherwise, ONE box. 15 bachelors degree DEGREE of naturalization 1 year ago? Ifto question currently enrolled, mark the 10 a. At Please copy THEname of MONTHS,fromthis 2, SKIPMastersdegree13. example: previous grade or Person MA, MS, MEng, any time IN the LAST 3college? 1 has page highest degree (for received. No, differen Include person attended school or questions below. MEd, MSW, MBA) then continue answering Puerto Rico Person is un only nursery or preschool, kindergarten, NO SCHOOLING COMPLETED 11 Professional degree beyond a or level of degree 13 What is this p What is the highest degree bachelors school question 16 Last Name elementary school, home school, and schooling this person MD, this p No, not a U.S. citizen (For example: (for example:has DDS, DVM, LLB, JD) which leads to Question on a college Population:a high school diploma orEducational AttainmentCOMPLETED? Mark (X) ONE box. b. Where didthis ho No schooling completed Yes, If currently enrolled, mark the previous grade or Cambodian, Ca degree. Address (Numbe 1 Please copy the name of Personthefrom page 2, Doctorate degree on this persons highest degreePRESCHOOL THROUGH GRADE 12 Frenchoutside NURSERY OR received. No, Canadia Whenthenthis person come to Enrollment did continue answering live in 9 Question on attended in the last 3 below. 12 This question focuses(for example: PhD, EdD) No, has not Schoolin questions Nigerian, Mexi BACHELORS DEGREE. Please print below the Puerto Rico MI First Name Print numbers boxes. United States? SKIP to question 11 NO major(s) of any BACHELORS DEGREES SCHOOLING COMPLETED months Last Name specific Nursery school or U.S. Virg Year then SKIP to this person has received.completed chemical No schooling (For example: Yes, public school, public college 14 (For example:p Kindergarten a. Does this Cambodian, Ca engineering, elementary teacher education, English at Questions as in the question through French Canadia NURSERY OR 12 if this F organizational psychology) Specify Yes, private school, private college, they appearAnswer questionnaire. 11person has a GRADE 12 Grade 1 PRESCHOOL THROUGH Nigerian, Mexi Name of city, to 7 Where was this person born? home school grade 1 or MI bachelors degree 11 higher. Otherwise, First Name Nursery school SKIP to question 13. 11 What is the highest degree or level of school 13 What is Yes p 10 a. At any time orUnitedLAST 3 MONTHS, has this b. What grade INlevel was thisPrint name of state. this In the THE States person attending? No, differen person attended school or college? Include Kindergarten this person has COMPLETED? Mark (X) ONE box. 14 a. PuertoNo p Does this Mark (X) ONE box. Rico only nursery or preschool, kindergarten, If currently enrolled, mark the previous grade or English at 13 What this p is the highest 11 Nursery school, preschool elementarycopy the name of Person 1 from school, Please was thishome school, and schoolingpage 2, 11 WhatGrade 1 throughdegree or level of school b. Where ofis thisco highest degree received. Specify b. What Name did is thi U.S. p 7which leads to a high school born? or a college Where person diploma this person1has NO DIPLOMAMark (X) ONE box. grade 11 12th grade COMPLETED? then continue answering questions below. Yes Puerto Rico Kindergarten If currently enrolled, mark the previous grade or degree. Outside the United States Print name of NO SCHOOLING COMPLETED Address (Numbe In the name of state. 12 Please copy the States Person 1 from Last Name Unitedname of PrintRico, Guam,page 2, This question focuses on this persons HIGH SCHOOL GRADUATE highest degree received. foreign country, orin the last 3 Puerto etc. No (For example: Grade 1 through 12 then continue answering questions below. No, has not attended Specify BACHELORS DEGREE. Please print below the No schooling completed Cambodian, Ca Regular high school diploma grade 1 SKIP to question 11 NO major(s) of any BACHELORS DEGREES SCHOOLING COMPLETED months 12 specific Last Name Frenchexample NURSERY OR PRESCHOOL THROUGH GRADE b. For Canadia What is thi this person hasgrade NO (For example: chemical 12 12th or alternative credential (For example: GEDschooling completed Yes, public school, public college Nigerian, Mexi No received. DIPLOMA Name of U.S. st First Name the United States Print name of MI engineering, elementary teacher education, Cambodian, Ca c. How well d Nursery school Outside HIGH SCHOOLPRESCHOOL THROUGH GRADE 12 Puerto Rico COLLEGE OR SOME French Canadia NURSERY OR GRADUATE Yes, private a citizen of the United States? organizational psychology)COLLEGE foreign country, private college, 8 Is this person school, or Puerto Rico, Guam, etc. Name of city, to Nigerian,this w Mexi 14 a. Does Very p Kindergarten school diploma home school College MI First Nameundergraduate years (freshman to Regular high credit, but less than 1 year of Some college Nursery school Yes, English at For example b. Whatsenior) or levelthe Unitedperson SKIP to 10a grade born in was this States attending? college through 11 Specify Grade 1credit Well GED or alternative credential ONE box. 14 a. Doeswell d Kindergarten 7Mark (X) Yes, bornprofessional school beyond a Where was or inperson Rico, Guam, the grade 1 11 this Graduate this Puerto born? c. How Yes p 1 or more years of college credit, no degree Not w bachelors degree (for example: MA or PhD English at U.S. COLLEGE OR through 11 Specify NurseryVirgin Islands, of Northern Marianas Grade 1 SOME COLLEGE In theschool, preschoolthe name of state. United States school) 8 Is this person medical oror Print United States? a citizen law program, this person Name of U.S. w Associates degree (for example: AA, AS) 7 Where was or abroad of born? No Veryat grade 1 11 credit, but less than 1 year of Not co Yes, born U.S. citizen parent Some college Puerto Rico Kindergarten in the United States SKIP to 10a Yes Yes, born or the United States Print name of state. parents college credit Bachelors degree (for example: BA, BS) In b. WhatWell is 8 Grade 1U.S. citizen bySpecify through 12 Rico, Guam, the No thi Yes, born in Puerto naturalization Print year 12th more years of college credit, no degree grade NO DIPLOMA 1 BACHELORS DEGREE AFTER or 15 a. Did this pe gradenaturalization States Print name of 1 12 United Not w U.S. Virgin Islands, or Northern Marianas of Outside the 1 year ago? HIGH SCHOOL GRADUATE b. WhatNot at is thi Associates degree (for example: AA, AS) foreign country, or Puerto Rico, Guam, etc. Masters degree (for example: MA, MS, MEng, Yes, born abroad of U.S. citizen parent 12th grade NO DIPLOMA Name of U.S. st MEd, MSW, MBA) diploma Regular high school example: BA, BS) or parents Person Outside the United States Print name of ACS-1(2009)KFI, Page 8, Base (Black) ACS-1(2009)KFI, Page 8, Green PantoneRico (2 Puerto 354 HIGH BachelorsGRADUATE SCHOOL degree (for For example questi foreign country, or Puerto Rico, Guam, etc. Professional degree beyond GED or alternative credentiala bachelors degree 15 a. Did this pe Yes, U.S. AFTER BACHELORS DEGREE Collegenot a citizen by naturalization Print year No, undergraduate years (freshman to U.S. citizen (for example: MD, DDS, DVM, c. How well th Regular high school diploma LLB, JD) of naturalization Yes, d 1 year ago? senior) For example COLLEGE OR SOME COLLEGE 8 Is this person a citizen of the United States? Masters degree (for example: Doctorate degree (for example: PhD, EdD) GED or alternative credential MA, MS, MEng, No, w Graduate or person come to live in the 9 When did this professional school beyond a Veryou MEd, college credit, c. How well d SomeMSW, MBA) but less than 1 year of Person Puerto Yes, born Print numbers in MA or bachelors degree United States SKIP to United States?in the(for example:boxes. PhD 10a COLLEGE ORcredit COLLEGE college SOME questi 8 Is this person medical orof the United States? or U.S Well Professional degree beyond a bachelors degree program, or a citizen law school) Year Yes,not a U.S. citizen Very th No, born in Puerto Rico, Guam, the then S (for example: MD, DDS, DVM,thanno year of Some college credit, but less LLB, degree Yes, w 1 or more years of college credit, 1JD) Yes, Virgin Islands, or Northern Marianas10a born in the United States SKIP to Not w U.S. college credit 12 (for example: PhD, EdD) Source: ACS-1(2009)KFI Wellou Doctorate degree 8 9 WhenYes, born person ofRico, to live parent No, Associates degree this person has a F Answer question if(for example: AA, AS) did this in Puerto U.S. citizen in the Not at abroad come Guam, the 1 or more years of higher. Otherwise, Puerto bachelors degree or college credit, no degree United States? Print numbers in boxes. Not w U.S. Virgin or parents Islands, or Northern Marianas Bachelors degree or U.S a. At SKIP to question 13. (for example: BA, BS) 10 Year any time IN THE LAST 3 MONTHS, has this Associates degree (for example: AA, AS) No, di then S Not at Yes, born abroad ofnaturalization Print year person U.S. citizenschool or college? Include attended by U.S. citizen parent AFTER BACHELORS DEGREE 15 a. Did this pe Puerto or parents of naturalization only nursery or Page 8, Base (Black) 1 year ago? Bachelors degree if this person has Green Pantone 354 (2 (for example: BA, a ACS-1(2009)KFI, preschool, kindergarten, ACS-1(2009)KFI, Page 8,BS) F Answer question 12 example: MA, MS, MEng, Masters degree (for elementary school, by naturalization schooling Yes, U.S. citizen home school, and Print year b. Did this pe bachelors degree DEGREE AFTER BACHELORS or higher. Otherwise, 15 a. Where did t MEd, MSW, MBA) which leads to a high school diploma or a college Person of naturalization 1 year ago? a. degree. time IN THE LAST 3 MONTHS, has this At any SKIP to question 13. 10 questi Address di Masters focuses on this persons Professional degree example: MA, MS, MEng, No, (N 12 This questiondegree (for beyond a bachelors degree person attended school or college? Include No, nothas not citizen in the last 3 MEd, MSW, MBA) (for example: MD, DDS, DVM, LLB, JD) Puerto No, a U.S. attended kindergarten, BACHELORS DEGREE. Please print below the Person Yes, th only nursery or preschool, months SKIP to question and questi specific major(s)degree beyond a bachelors degree elementary school, home school, 11 schooling Professional of any BACHELORS EdD) Doctorate degree (for example: PhD,DEGREES No, ou b. Where did t did this U.S. citizen 9 WhenNo, leads to a highcome to live in or a college this person has received. (For example: chemical whichYes, public school, public college not a person school diploma the (for example: MD, DDS, DVM, LLB, JD) Yes, th Puerto United States? Print numbers in boxes. degree. engineering, elementary teacher education, Address (N or U.S Doctorate degree (for 12 This question psychology) example: PhD, EdD) private school, private organizational focuses on this persons No, ou When Yes,has not attended to live in 3 the 9 Year did this person comein the college, then S No, school last BACHELORS DEGREE. Please print below the Name of ci home Print numbers in boxes. Puerto United States? SKIP to question 11 months specific major(s) of any this person has a BACHELORS DEGREES or U.S Answer question 12 if b. What grade or level was this person attending?F this person has received. (For example: chemical Year then S Yes, public school, public college Mark (X) ONE box. bachelors degree or higher. education, Otherwise, engineering, elementary MEETING FEDERALSKIP to question 13. ifteacher NEEDS psychology) person has a Answer question 12 this 10 a. At any time IN THE LAST 3 MONTHS, has this F organizational Yes, private school, private college, Nursery school, preschool No, ci Name of di U person attended school or college? Include home school bachelors degree or higher. Otherwise, Puerto only nursery or preschool, kindergarten, Puerto Ric Kindergarten LAST 3 MONTHS, has this are SKIP to question 13. assessing the Educational attainmentlevel was this person attending? needed for use in b. At any time or THE school enrollment data What grade IN and 10 a. elementary school, home school, and schooling No, di b. Where did t Mark Grade 1 through 12 Specify or a college person ONE box. ofschool college? Include socioeconomic(X)attended schoolordiploma children. Government agencies also require these data condition which leads to a high school-age Puerto only nursery or 12 preschool, kindergarten, grade 1 degree. for funding allocations and preschool and schooling 12 This question focuses on this persons Address (N Nursery school, program elementary school, home school, planning and implementation. These data are needed Name did t b. Where of U whichNo, has not attended indiploma 3 a citizens in language minorities in order to meet leads to a of school the or BACHELORS DEGREE. Please print below the to determine the extenthighilliteracy rates ofcollege Name of U Puerto Ric Kindergarten to question last degree. months 11 Address (N statutory requirements SKIP under the Voting Rights Act. This question focuses on this personsDEGREES Puerto Ric 12 specific major(s) of any BACHELORS chemical Grade 1 notschool, public college through 12 in the last 3 Specify this person has received. (For example: No, public attended BACHELORS DEGREE. Please print below the Yes,has undergraduate years (freshman to College 12 grade 1 engineering, elementary teacher education, months SKIP to question 11 specific major(s) of any BACHELORS DEGREES senior) Yes, private school, private college, organizational psychology) (For example: chemical this person has received. Name of U Yes, public school, public school beyond a college home schoolprofessional Graduate or Name of ci engineering, elementary teacher education, bachelors level was this person attending? degree (for example: MA or PhD Puerto Ric b. WhatYes, private school, private college, grade or organizational psychology) program, or medical or law school) Name of ci Mark (X) ONE undergraduate years (freshman to home school College box. b. Whatsenior) or level was this person attending? grade Nursery school, preschool Name of U 8 Mark (X) ONE box.professional school beyond a Graduate or Puerto Ric Kindergarten bachelors degree (for example: MA or PhD Nursery school, preschool program, or medical or law school) Name of U Grade 1 through 12 Specify Puerto Ric Kindergarten grade 1 12 ACS-1(2009)KFI, Page 8, Green Pantone 35 8 ACS-1(2009)KFI, Page 8, Base (Black) Grade 1 through 12 Specify Name of U grade 1 12 Puerto Ric College undergraduate years (freshman to Name of U
Year Yes, born abroad of U.S. citizen parent or parents
Person 1
Associates degree (for example: AA, AS)
Person 1 American Community Survey
Person 1 Person 1
.4{y
.4{y
.4{y .4{y
ACS-1(2009)KFI, Page 8, Green Pantone 35

Population: Question on Educational Attainment Question on School Enrollment
COMMUNITY BENEFITS
Education Based on data about educational attainment, school districts are allocated funds to provide classes in basic skills to adults who have not completed high school. The U.S. Department of Education uses school enrollment data to develop adult education and literacy programs based on the number of individuals with limited English proficiency. Government The U.S. Department of Justice uses school enrollment data in the enforcement work against discrimination in education. Employment Employers use information about the educational attainment levels of the labor force to locate new jobs and stimulate economic growth.
www.census.gov
of naturalization No, not a U.S. citizen
Professional degree beyond a bachelors degree Masters degree (for example: MA, MS, MEng, (for example: MD, DDS, DVM, LLB, JD) MEd, MSW, MBA) Doctorate degree (for example: PhD, EdD) Professional degree beyond a bachelors degree (for example: MD, DDS, DVM, LLB, JD)
1 year ago? 16 question
hen did this person come to live in the No, not a U.S. citizen nited States? Print numbers in boxes. ar did this person come to live in the hen nited States? Print numbers in boxes. Population: ar
Doctorate Survey American Community degree (for example: PhD, EdD)
Question on Field of if this person has a F Answer question 12 Degree
At any time IN THE LAST 3 MONTHS, has this person attended school or college? Include
bachelors degree or higher. Otherwise, only nursery or preschool, kindergarten, At any time IN THE LAST 3 MONTHS, has this Question as it appears in the questionnaire. SKIP to question 13. elementary school, home school, and schooling which leads to a high school college? a college person attended school ordiploma orInclude degree. only nursery or preschool, kindergarten, elementary school, home school, and schooling 12 This question focuses on this persons BACHELORS DEGREE. Please print below the whichNo, has nothigh school diploma 3 a college leads to a attended in the last or months SKIP to question 11 specific major(s) of any BACHELORS DEGREES degree.
bachelors degree or higher. Otherwise, SKIP to question 13. if this person has a Answer question 12
Yes, this under 1 SKIP to SKIP 16 Person ishouse year oldquestionto question 16 the United States and No, outside Puerto Rico PrintSKIP toof foreign 16 Yes, this house name question co or U.S. Virgin Islands, Guam, etc., belo thenoutside the United16 No, SKIP to question States and Puerto Rico Print name of foreign co or U.S. Virgin Islands, Guam, etc., belo then SKIP to question 16
No, different house in the United State Puerto Rico
No, different house in 1 year ago? b. Where did this person livethe United State Puerto Rico Address (Number and street name) b. Where did this person live 1 year ago? Address (Number and street name) Name of city, town, or post office Name of city, town, or post office Name of U.S. county or municipio in Puerto Rico Name of U.S. county or municipio in Puerto Rico Name of U.S. state or Puerto Rico ZIP Code ZIP Code
Yes,has notschool, public college No, public attended in the last 3 months SKIP to question college, Yes, private school, private 11 home school Yes, public school, public college What grade or level was this person attending? Yes, private Mark (X) ONE box.school, private college, home school WhatNurseryor level was this person attending? grade school, preschool Mark (X) ONE box. Kindergarten Nursery school, preschool Grade 1 through 12 Specify grade 1 12 Kindergarten Grade 1 through 12 Specify grade 1 12
12 This person has received. this persons chemical this question focuses on (For example:
BACHELORS DEGREE.teacher education, the engineering, elementary Please print below specific major(s) of any BACHELORS DEGREES organizational psychology) this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology)
.4{y .4{y
College undergraduate years (freshman to Field of Degree (FOD) data are needed for use in assessing the qualifications Name of U.S. state or of the U.S. senior) Puerto Rico college-educated workforce. Government agencies will use these data to examine the supply of Graduate or professional school beyond to a College undergraduateexample: MA or PhD bachelors degree (for years (freshman in a variety of fields, the need to encourage greater participation in highly-skilled workers senior) or medical or law school) program, certain fields, beyond a Graduate or professional schooland the representation of different demographic groups in various fields of study. bachelors degree (for example: MA or PhD program, or medical or law school)
COMMUNITY BENEFITS 8, Green Pantone 354 (20, 40, 50 and 100% ACS-1(2009)KFI, Page
Education Government ACS-1(2009)KFI, Page 8, Base (Black) ACS-1(2009)KFI, Page 8, Green Pantone 354 (20, 40, 50 and 100% College administrators, educators, The National Science Foundation (NSF) students, parents and professional uses these data to draw a sample for societies use these data to assess how a large workforce survey, the National graduates in various fields are faring in Survey of College Graduates, which the job market as well as informing them gathers important information about the about the kinds of training graduates education, employment and characteristics should be receiving to be prepared for of scientists and engineers. NSF and the jobs that are likely to be available. other agencies use the data to analyze the It provides timely information for types of jobs that graduates in a particular prospective students and their parents field hold, their earnings and how these about employment possibilities for those outcomes vary within and across fields by majoring in a particular field in college. race/ethnicity, gender, and citizenship. Employment Employers use information about the field of degree of college graduates to assess the supply of potential employees, nationally and in specific areas.
www.census.gov

Population: Question on Ancestry
13199088
Question as it appears in the questionnaire.
13 What is this persons ancestry or ethnic origin? What is the highest degree or level of school his person has COMPLETED? Mark (X) ONE box.
currently enrolled, mark the previous grade or ighest degree received.
O SCHOOLING COMPLETED
No schooling completed Nursery school Kindergarten Grade 1 through 11 Specify grade 1 11
URSERY OR PRESCHOOL THROUGH GRADE 12
(For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
14 a. Does this person speak a language other than Source: ACS-1(2009)KFI

English at home? Yes
MEETING FEDERAL NEEDS No SKIP to question 15a

12th grade NO DIPLOMA
Ancestry identifies the ethnic b. What is this language? origins of the population. Federal agencies regard this information as essential for fulfilling many important needs. Ancestry is required to enforce provisions IGH SCHOOL GRADUATE under the Civil Rights Act, which prohibits discrimination based upon race, sex, religion, and Regular high school diploma national origin. More generally, For example: Korean, Italian, Spanish, Vietnamese social and economic these data are needed to measure the characteristics of ethnic groups and to tailor services to accommodate cultural differences. GED or alternative credential
c. How well does this person speak English? Very well Well Not well Not at all Did this person live in this house or apartment 15 a.COMMUNITY BENEFITS Some college credit, but less than 1 year of college credit 1 or more years of college credit, no degree Associates degree (for example: AA, AS) Bachelors degree (for example: BA, BS)
OLLEGE OR SOME COLLEGE
FTER BACHELORS DEGREE
Rights Act. Answer question 12 if groups. this person has a bachelors degree or higher. Otherwise, Health Service Act, Under the Public SKIP to question 13. ancestry is one of the factors used in No, different house in the United States or Puerto identifying segments of the populationRico who may not be receiving b. Where medical needed did this person live 1 year ago? services. Address (Number and street name)
1 year ago? Masters degree (for example: MA, MS, MEng, MEd, MSW, MBA) Person is under 1 year old SKIP to Employment question 16 Professional degreeSocial a bachelors degree beyond Services (for example: MD, DDS, DVM, LLB,ancestry assist states Yes, this house Data to question 16 JD) SKIP about ancestry are used to evaluate Data about and local Doctorate degree (for example: to develop health care and other the Unitedeffectiveness of equal employment PhD, EdD) agencies the States and No, outside Puerto Rico services tailored to meet the language and Print name of foreign country,and programs for opportunity policies or U.S. Virgin Islands, Guam, etc., below; cultural diversity of the elderly in then SKIP to question 16 these different ethnic groups under the Civil
his question focuses on this persons BACHELORS DEGREE. Please print below the pecific major(s) of any BACHELORS DEGREES his person has received. (For example: chemical ngineering, elementary teacher education, rganizational psychology)
www.census.gov
Name of city, town, or post office
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or Puerto Rico
ZIP Code
13199088
Population: O SCHOOLING COMPLETED

No schooling completed Nursery school Kindergarten Grade 1 through 11 Specify grade 1 11
currently enrolled, mark the previous grade or ghest degree received.
13 What is this persons ancestry or ethnic origin? hat is the highest degree or level of school is person has COMPLETED? Mark (X) ONE box.
Question on Language Spoken at Home

(For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Question as it appears Korean, questionnaire. in the Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
URSERY OR PRESCHOOL THROUGH GRADE 12
14 a. Does this person speak a language other than

English at home? Yes No SKIP to question 15a b. What is this language?
12th grade NO DIPLOMA Regular high school diploma GED or alternative credential Some college credit, but less than 1 year of college credit 1 or more years of college credit, no degree Associates degree (for example: AA, AS) Bachelors degree (for example: BA, BS)
GH SCHOOL GRADUATE For example: Korean, Italian, Spanish, Vietnamese
OLLEGE OR SOME COLLEGE
c. How well does this person speak English? Very well Well Not well Not at all
Source:a. Did this person live in this house or apartment 15 ACS-1(2009)KFI
TER BACHELORS DEGREE
1 year ago? Masters degree (for example: MA, MS, MEng, MEETING under 1 year old NEEDS MEd, MSW, MBA) Person is FEDERAL SKIP to question 16 Professional degree beyond a bachelors degree information on language spoken at home for their programs that Government agencies use (for example: MD, DDS, DVM, LLB, JD) serve the needs of the foreign-bornYes, this house SKIP to question 16 and specifically those who have difficulty with English. Doctorate degree (for example: PhD, EdD) No, is needed to meet statutory requirements for making Under the Voting Rights Act, language outside the United States and Puerto Rico Print name of foreign country, voting materials available in minority U.S. Virgin Islands, Guam, etc., the Census Bureau is directed, or languages. Specifically, below; then SKIP and the 16 using data about language spoken at home to questionability to speak English, to identify minority
groups that speak nswer question 12 if this person has a a language other than English and to assess their English-speaking ability. The U.S. Department of Education uses these data to prepare a report to Congress on the social achelors degree or higher. Otherwise, KIP to question 13. and economic status of children served by different local school districts. No, different house in the United States or Puerto Rico
b. Where did this person live 1 year ago?
Address (Number and is question focuses on this persons COMMUNITY street name) BENEFITS ACHELORS DEGREE. Please print below the ecific major(s) of any BACHELORS DEGREES Education Social Services is person has received. (For example: chemical gineering, elementary teacher education, Data on language are used to allocate State and local agencies concerned with ganizational psychology) Name of city, town, or post office grants to school districts for children with aging develop health care and other
limited English language proficiency.
services tailored to the language and cultural diversity of the elderly under the State and local educational agencies Older Americans Act. receive grants for programsName of U.S. county or municipio in to improve Puerto Rico educational skills, complete secondary schooling, and provide job training and Government placement for adults based on data about Under the Voting Rights Act, these data language. Name of U.S. state or are needed to assess the fairness of voting Puerto Rico ZIP Code practices in governmental subdivisions.
www.census.gov
ACS-1(2009)KFI, Page 8, Green Pantone 354 (20, 40, 50 and 100%)
GH SCHOOL GRADUATE
1 or more years of college credit, no degree 12th grade NO DIPLOMA Associates degree (for example: AA, AS) Bachelors degree (for example: BA, BS) Regular high school diploma
Not well b. What is this language? Not at all
15 a. Did this person live in this house or apartment For example: Korean, Italian, Spanish, Vietnamese 1 year ago? GED or alternative credential Masters degree (for example: MA, MS, MEng, c. How well does this person speak English? OLLEGE MSW, MBA) Population: Question on Residence 1 old SKIP to MEd, OR SOME COLLEGE Person is under 1 year Year Ago question 16 Very well Professional degree beyond a bachelors degree Some college credit, but less than 1 year of (for example: MD, DDS, DVM, LLB, JD) college credit Yes, this house SKIP to question 16 Well Doctorate degree of college credit, noEdD) 1 or more years (for example: PhD, degree No, outside the United States and Not well name questionnaire. Associates degree (for example: AA, AS) QuestionPuerto Rico Printin theof foreign country, as at all Notit Virgin Islands, Guam, etc., below; or U.S. appears then SKIP to question 16 Bachelors degree (for example: BA, BS)
TER BACHELORS DEGREE
nswer question 12DEGREE FTER BACHELORS if this person has a 15 a. Did this person live in this house or apartment 1 year ago? achelors degree or higher. Otherwise, Masters degree (for example: MA, MS, MEng, KIP MEd, MSW, MBA) to question 13. No, different house year old SKIP to or Person is under 1 in the United States Puerto Rico question 16 Professional degree beyond a bachelors degree (for example: MD, DDS, DVM, LLB, JD) b. WhereYes, this house live 1 to question 16 did this person SKIP year ago? Doctorate degree (for example: PhD, EdD) No, outside and street name) Address (Numberthe United States and s question focuses on this persons Puerto Rico Print name of foreign country, ACHELORS DEGREE. Please print below the or U.S. Virgin Islands, Guam, etc., below; ecific major(s) of any BACHELORS DEGREES then SKIP to question 16 s person has received. (For example: chemical Answer question 12 teacherperson has a gineering, elementary if this education, bachelors degree or higher. Otherwise, ganizational psychology) Name of city, town, or post office SKIP to question 13. No, different house in the United States or Puerto Rico b. Where did this person live 1 year ago? Name of U.S. county or municipio in Address (Number and street name) Puerto Rico
his question focuses on this persons ACHELORS DEGREE. Please print below the pecific major(s) of any BACHELORS DEGREES his person has received. (For example: chemical ngineering, elementary teacher education, rganizational psychology)
Name of U.S. state or Puerto Rico Name of city, town, or postZIP Code office
Name of U.S. county or municipio in Puerto Rico
Name of U.S. state or Puerto Rico
ZIP Code
ACS-1(2009)KFI, Page 8, Green Pantone 354 (20, 40, 50 and 100%) Residence 1 year ago is used to assess the residential stability and the effects of migration in both urban and rural areas. This item provides information on the mobility of our population. Knowing the number and characteristics of movers is essential for federal programs dealing with employment, housing, education, and the elderly. The U.S. Department of Veterans Affairs develops its mandated projections of the need for hospitals and other veteran benefits for each state with migration data about veterans. The Census Bureau develops state age and sex estimates and small-area population projections based on data about residence 1 year ago.

Population: Question on Residence 1 Year Ago
COMMUNITY BENEFITS
Social Services State and local agencies concerned with aging develop health care and other services for the elderly using information on where people lived 1 year ago. These data indicate changes in the location of seniors that may affect the need for future services in specific areas. Local governments use data about migration to forecast the demand for new public facilities such as schools, hospitals, libraries, and fire and police stations. Government Planners and policy makers use data about the number of persons moving into, or out of, an area to estimate state and county population growth. Research, based on data about migration, shows changes in the socioeconomic profiles of areas. These data are used by many government agencies for program planning, especially for rural parts of the country.
www.census.gov

Population: Question on Health Insurance Coverage
1319909
Person 1 (continued)
Is this person CURRENTLY covered by any of the more than one grandchild, answer the q following types of health insurance or health Question as it appears in the questionnaire. H Answer the grandchildif this persongrandpa for question 19 for whom the is been responsible Otherwise, SKIP to coverage plans? Mark "Yes" or "No" for EACH type 15 years old or over.for the longest period o of coverage in items a h. the questions for Person 2 on page 12. 19 Because of CURRENTLY covered by any of 16 Is this person a physical, mental, or emotionalthe Less than 6 months Yes No condition, does health insurance or health following types ofthis person have difficulty a. Insurance through a current or doing errands alone such as visiting a doctors coverage plans? Mark "Yes" or "No" for EACH type 6 to 11 months former employer or union (of this office or shopping? of coverage in items a h. person or another family member) 19 Because of a physical, mental, or emotion 1 or 2 years Yes No condition, does this person have difficult b. Insurance purchased directly from Yes a. Insurance through a current or 3 or alone doing errands 4 yearssuch as visiting a doc an insurance company (by this former employer or union (of this office or shopping? No person or another family member) person or another family member) 5 or more years c. Medicare, for people 65 and older, b. Insurance purchased directly from Yes 20 What is this persons marital status? or people with certain disabilities an insurance company (by this 26 Has this person ever served on active d No person or another family member) U.S. Armed Forces, military Reserves, o Now married d. Medicaid, Medical Assistance, or Guard? Active duty does not include trainin c. Medicare, for people 65 and older, any kind of government-assistance 20 What is this persons maritalbut DOES inclu Reserves or National Guard, status? Widowed or people with certain disabilities plan for those with low incomes activation, for example, for the Persian Gulf or a disability Divorced Now married d. Medicaid, Medical Assistance, or Yes, now on active duty any kind of government-assistance Separated e. TRICARE or other military health care Widowed plan for those with low incomes Yes, on active duty during or a disability Never married SKIP to I Divorced 12 months, but not now f. VA (including those who have ever the last used or enrolled for VA health care) Separated active duty in the past, but no e. In the PAST 12 MONTHShealth care TRICARE or other military did this person get Yes, on 21 g. Indian Health Service during the last 12 months Yes No Never married SKIP to I f. VA (including those who have ever No, training for Reserves or National used or enrolled for VA health care) h. Any other type of health insurance a. Married? only 12 MONTHS did this 21 In the PAST SKIP to question 28aperson g or health coverage plan Specify g. Indian Health Service Yes No No, never served in the military SK b. Widowed? question 29a h. Any other type of health insurance a. Married? c. Divorced? or health coverage plan Specify 27 When did this person serve on active du b. U.S. Armed Forces? Mark (X) a box for EA Widowed? 22 How many times has this person been married? in which this person served, even if just for a. Is this person deaf or does he/she have serious difficulty hearing? c. period. Divorced? Once September 2001 or person 22 How many times has this later been ma Two times Yes 17 ACS-1(2009)KFI Source: a. Is this person deaf or does he/she have August 1990 to August 2001 (includin serious difficulty hearing? Three or more times No Once Persian Gulf War) b. Is this person blind or does he/she have Two times Yes September 1980 to July 1990 23 In what year did this person last get married? serious difficulty seeing even when wearing Three or more times 1980 May 1975 to August glasses? Year No Yes
Answer question 19 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.
c. How long has this grandparent been responsible for the(se) grandchild(re
If the grandparent is financially responsi
b. Is this person blind or does he/she have year did this person last get marr 23 In whatVietnam era (August 1964 to April 19 serious difficulty seeing even when wearing March 1961 to July 1964 glasses? Year No MEETING FEDERAL NEEDS February 1955 to February 1961 Yes I American Community person is This questionperson is was added to the Answer question 24 if thisSurvey (ACS) to enable the U.S. Answer question 18a c if this Korean War (July 1950 to January 19 female and 15 50 years old. Otherwise, No Department of Health other federal agencies to more accurately 5 years old or over. Otherwise, SKIP to and Human Services and 25a. SKIP to question January 1947 to June 1950 distribute resources the questions for Person 2 on page 12. and better understand state and local health insurance needs. question 24 if this person is I AnswerWorld War II (December 1941 to Dece G Answer question 18a c if this person is female and 15 50 years old. Otherwise, 5 Has this or over. programs requires accurateSKIP toand local25a. or earlier Planning and implementing 24 years oldperson given birth to SKIP to many federal healthOtherwise, any children in state November 1941 question a. Because of a physical, mental, or emotional the past 12 for Person the questions months? 2 on page 12. information on health insurance status. Obtaining data on the uninsured rate among Americans condition, does this person have serious difficulty concentrating, remembering, or policy makers at federal, state, and local levels. 28 a. Does this person have a VA service-c is of great importance to Yes disability rating? 24 Has this person given birth to any childre making decisions? 18 a. Because of a physical, mental, or emotional the past 12 months? No condition, does this person have serious Yes (such as 0%, 10%, 20%, ... , 10 Yes difficulty concentrating, remembering, or 25 a. Does this person have any of his/her own Yes No SKIP to question 29a making decisions? grandchildren under the age of 18 living in No No this house or apartment? b. Does this person have serious difficulty Yes Does this this persons service-connec 25 a. b. What is person have any of his/her ow Yes walking or climbing stairs? disability rating? grandchildren under the age of 18 livin No this house or apartment? No SKIP to question 26 Yes 0 percent b. Does this person have serious difficulty b. Is this or climbing stairs? Yes or 20 percent walking grandparent currently responsible for No 10 most of the basic needs of any grandchild(ren) No SKIP to question 26 c. Does this person have difficulty dressing or under the age of 18 who live(s) in this house or Yes 30 or 40 percent bathing? apartment? b. Is this grandparent currently responsib No 50 or 60 percent most of the basic needs of any grandch Yes Yes 70 percent or higher c. Does this person have difficulty dressing or under the age of 18 who live(s) in this h bathing? SKIP to question 26 apartment? No No Yes Yes

Population: Question on Health Insurance Coverage
COMMUNITY BENEFITS
Social Services One of the nations important sources of insurance data, the Current Population Survey, has annual sample sizes that are too small for many states. Adding a health insurance question to the ACS offers an improved data source to smaller states and communities. State and localities will use the statistically reliable county-level data on the uninsured to more efficiently target outreach and enrollment efforts to those who are eligible for Medicaid and the State Childrens Health Insurance Program, but are not enrolled, thereby facilitating increased insurance coverage. Public Health Measuring health insurance status helps agencies target public health grant resources to locations where need is great.
www.census.gov
Yes, on active the last 12on Yes, now mo Yes, on active Yes, on active g. Indian Health Service during the las f. VA (including those who have ever the last 12 mo used or enrolled for VA health 18301930, since 1970 asked care) No, training f h. Any other type of health insurance In Married? Yes, onSKIP t active 21 a. the PAST 12 MONTHS did this person get only the las g. or health coverage plan Specify Indian Health Service during Yes No Population: Question on Disability b. Widowed? No, never ser No, training h. Any other type of health insurance a. Married? question 29aft c.only long h How SKIP or health coverage plan Specify Answer question 19 if this person is H Divorced? c. responsible did this ser 27 WhenNo, neverper b. Widowed? old or over. Otherwise, SKIP to 15 years If the Force U.S. Armed grandp question 29a the questions for Person 2 on page 12. 22 How many times has this person been married? more person in which this than o a. this person deaf orQuestions as by any of the in the questionnaire. does he/she have 17 16 IsIs this person CURRENTLY coveredthey appear c. Divorced? following types of health When for this per 27 period.did the gran serious difficulty hearing? insurance or health been Force Once coverage plans? Mark "Yes" or "No" for EACH type U.S. Armedrespon 22 How many times has this person been married? September 20 in which this perso this person items a h. 17 a. Isof coverage indeaf or does he/she have 19 Because of a physical, mental, or emotional Two times Yes Less th period. serious difficulty hearing? Yes No condition, does this person have difficulty August 1990 t Once or more times a. Insurance through a current or Threeerrands alone such as visiting a doctors No doing to W Persian6Gulf20 former employer or union (of this September 11 Two or shopping? officetimes Yes b. Is this personanother family member) person or blind or does he/she have September 19 23 In what year did this person last get married? August1 or 2 1990 serious difficulty seeing even when wearing Three or more times No b. Insurance purchased directly from Yes Persian3Gulf W May 1975 to A glasses? Year or 4 an insurance company (by this have b. Is this personanother family member) September 19 No person or blind or does he/she 23 In what year did this person last get married? Vietnam eram 5 or ( serious difficulty seeing even when wearing Yes c. Medicare, for people 65 and older, May 1975 to A glasses? Year March 1961 to 20 What is this persons marital status? or people with certain disabilities No 26 Has this perso Vietnam 1955 February era Yes U.S. Armed F( Now marriedif this person is d. Medicaid, Medical Assistance, or I Answer question 24 Guard? 1961 to March Active any of 18a questiongovernment-assistance Korean or Na G AnswerNokindthose with c if this person is female and 15 50 years old. Otherwise, Reserves War ( Widowed plan for over. Otherwise, SKIP to low incomes 5 years old or February 195 activation,1947 SKIP to question 25a. January for e or a disability Divorced I Answer question 24 if this person is the questions for Person 2 on page 12. is 18a c if this person Korean War G Answer question othermilitary health care female and 15 50 years old. Otherwise, World War II( Yes, now Separated e. TRICARE or 5 years old or over. Otherwise, SKIP to SKIP to question 25a. birth to any children in January 1947 24 Has this person given November 19 Yes, on a the f. VA (including those mental, ever questions for Person 2 on page 12. Never married 18 a. Because of a physical, who haveor emotional the past 12 months? SKIP to I the last World War II1 condition, does this person have serious used or enrolled for VA health care) 28 a. Does this perso Yes, on a Has this person 12 MONTHS did this person get 24 21 In the PAST given birth to any children in difficulty concentrating, remembering, or November 19 Yes disability ratin g. Indian Health Service during th 18 a. making decisions? Because of a physical, mental, or emotional the past 12 months? Yes No No condition, does this person have serious No, traini this perso 28 a. DoesYes (such h. Any other type of health insurance a.Yes Married? difficulty concentrating, remembering, or Yes only S disability ratin or health coverage plan Specify 25 a. Does this person have any of his/her own making decisions? No neve grandchildren under the age of 18 living in No, SKIP b.No Widowed? No Yes (such this house or apartment? question Yes 25 a. Does this person have any of his/her own b. Does this person have serious difficulty c. Divorced? b. When this pe is this 27WhatNodid SKIP grandchildren under the age of 18 living in Yes walking or climbing stairs? No disability ratin U.S. Armed Fo or apartment? How many times has this person been married? 22 this house SKIP to question 26 No in which this pe this 17 DoesYes person have serious difficulty b. a. Isthis person deaf or does he/she have b. What0is this pe percent period. serious difficulty hearing? Yes walking or climbing stairs? Once disability ratin b. Is this grandparent currently responsible for No 10 or 20 pe Septemb most No the basic needs of26 grandchild(ren) of SKIP to question any Two times Yes Yes 0 or 40 pe c. Does this person have difficulty dressing or under the age of 18 who live(s) in this house or 30percent1 August b. apartment? or morecurrently responsible for Is this Three grandparent times bathing? No No 10 or 20 pe Persian G 50 or 60 pe most of the basic needs of any grandchild(ren) b. Isthis person blind or does he/she have this c. DoesYes person have difficulty dressing or under theyear did this person last this married? age of 18 who live(s) in get house or Septemb Yes 30 or 40 pe 23 In what 70 percent serious bathing? difficulty seeing even when wearing apartment? May 1975 glasses? No 50 or 60 pe YearNo SKIP to question 26 Yes Yes Vietnam 70 percent Yes Source: ACS-1(2009)KFI No No SKIP to question 26 March 19 No February I Answer question 24 if this person is Korean W G Answer question 18a c if this person is female and 15 50 years old. Otherwise, ACS-1(2009)KFI, Page 9, BaseSKIP to ACS-1(2009)KFI, Page 9, Green Pantone 354 (10 5 years old or over. Otherwise, (Black) SKIP to question 25a. January 1 MEETING FEDERAL NEEDS the questions for Person 2 on page 12. World W ACS-1(2009)KFI, Page 9, Base (Black) ACS-1(2009)KFI, Page and Information on disability is used by a number of federal agencies togiven birth tofunds9, Green Pantone 354 (10 24 Has this person distribute any children in Novembe developa. Because of a physical, mental, or emotionalFor example, data about the size, distribution, 18 programs for people with disabilities. the past 12 months? condition, does this person haveare essential for developing disability employment serious and needs of the disabled population 28 a. Does this p difficulty concentrating, remembering, or disability r policy. For the Americans with Disabilities Act, data aboutYes functional limitations are important making decisions? No to ensure that comparable public transportation services are available for all segments of the Yes (s Yes population. Federal grants are awarded, under the Older Americans Act, basedof his/hernumber 25 a. Does this person have any on the own No of elderly people with physical and mental disabilities. grandchildren under the age of 18 living in No this house or apartment? b. Does this person have serious difficulty b. What is thi Yes walking or climbing stairs? disability r No SKIP to question 26 Yes 0 perc b. Is this grandparent currently responsible for No 10 or 2 most of the basic needs of any grandchild(ren) c. Does this person have difficulty dressing or under the age of 18 who live(s) in this house or 30 or 4 bathing? apartment? 50 or 6 Yes Yes 70 per
plan for or other military health e. TRICAREthose with low incomes care or a disability f. VA (including those who have ever e. used or enrolled for VA health care) TRICARE or other military health care
DISABILITY American Community Survey

Widowed Separated Divorced Never married SKIP to I Separated 21 In the PAST 12 MONTHS did this person get Never married SKIP to I Yes No
activation, for exam
Yes, now on a
.4{ .4{
No
No SKIP to question 26
.4{

Population: Question on Disability
COMMUNITY BENEFITS
Transportation Disability data are used to allocate funds for mass transit systems to provide handicapped facilities. Under the Americans with Disabilities Act, local transit authorities use these data on the number of individuals with functional limitations in order to ensure public transportation services are comparable to those for individuals without disabilities. Employment Data about people with disabilities are used to allocate funds to states and local areas for employment and job training programs for veterans. Social Services Under the Older Americans Act, these data assist state and local agencies concerned with aging to develop health care and other services tailored to the disabilities of the elderly. Disability data are used by state and county agencies to plan for eligible recipients under the Medicare and Medicaid programs.
www.census.gov
erson 1 (continued)
this person CURRENTLY covered by any of the llowing types of health insurance or health verage plans? Mark "Yes" or "No" for EACH type coverage in items a h. 19 Because of a physical, mental, or emotional Yes No condition, does this Population: Question on Maritalperson have difficulty Status Insurance through a current or doing errands alone such as visiting a doctors former employer or union (of this office or shopping? person or another family member)
Answer question 19 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.
c. How long has this grandparent been responsible for the(se) grandchild(ren)?

Yes
If the grandparent is financially responsible f more than one grandchild, answer the questi for the grandchild for whom the grandparent been responsible for the longest period of tim
Less than 6 months 6 to 11 months 1 or 2 years 3 or 4 years 5 or more years
Insurance purchased directly from an insurance company (by this person or another family member)
Question as it appears in the questionnaire. No

20 What is this persons marital status?
Now married Widowed Divorced Separated Never married SKIP to I
Source: In the PAST 12 MONTHS did this person get 21 ACS-1(2009)KFI
Medicare, for people 65 and older, or people with certain disabilities
26 Has this person ever served on active duty
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf Wa
U.S. Armed Forces, military Reserves, or N Guard? Active duty does not include training fo
TRICARE or other military health care
Yes, now on active duty Yes, on active duty during the last 12 months, but not now Yes, on active duty in the past, but not during the last 12 months
VA (including those who have ever used or enrolled for VA health care)
Indian Health Service
Yes
No
Any other type of health insurance or health coverage plan Specify
a. Married? b. Widowed? c. Divorced? MEETING
No, training for Reserves or National Gua only SKIP to question 28a
27 When did this person serve on active duty i U.S. Armed Forces? Mark How many times has programs calls for accurate in which this person served, (X) a box for EACH 22 many government this person been married? Planning and have information on even if just for part Is this person deaf or does he/she implementing period. serious difficulty marital status, such as the number of married women in the labor force, elderly widowed hearing? Once individuals, or young single people who soon may establish homes of their own. For the or later September 2001 Two times Yes U.S. Department of Housing and Urban Development, data about marital statusAugust define August 2001 (including help 1990 to Three or more times No Persian Gulf War) qualifying census tracts for the Low-Income Housing Tax Credits and the Mortgage Revenue Is this person blind or does he/she have Bonds Programs. September 1980 to July 1990 23 In what year did this person last get married?
Year May 1975 to August 1980 Vietnam era (August 1964 to April 1975) March 1961 to July 1964 February 1955 to February 1961 Korean War (July 1950 to January 1955) January 1947 to June 1950 Yes No
FEDERAL NEEDS
No, never served in the military SKIP to question 29a
serious difficulty seeing even when wearing glasses?
nswer question 18a c if this person is years old or over. Otherwise, SKIP to e questions for Person 2 on page 12.
Answer question 24 if this person is female and 15 50 years old. Otherwise, SKIP to question 25a. COMMUNITY BENEFITS
November 1941 or earlier Because of a physical, mental, or emotional the past 12 months? Data about marital status are used for Local governments use data about marital condition, does this person have serious 28 a. Does this person difficulty concentrating, remembering, or budget and resource planningYes identify to status in assessing needs for housing and have a VA service-conn disability rating? making decisions? the number of children needing special other community development services. No Yes (such as 0%, 10%, 20%, ... , 100%) services (e.g., children in single-parent Yes 25 a. Does this person have any of his/her own households). No SKIP to question 29a grandchildren under the age of 18 living in No Employment thisabout or apartment? house Does this person haveCommunities use census data serious difficulty b. What is this Community organizations use data persons service-connected marital status to pinpoint areas with large Yes walking or climbing stairs? disability rating? about marital status to identify needs for numbers of single-parent families and No SKIP to question 26 Yes job training and housing for displaced 0 percent identify needs for childcare, medical care, b. Is this grandparent currently responsible for homemakers. No and other social services. most of the basic needs of any grandchild(ren) 10 or 20 percent Does this person have difficulty dressing or under the age of 18 who live(s) in this house or 30 or 40 percent bathing? apartment? www.census.gov 50 or 60 percent Yes Yes 70 percent or higher No No SKIP to question 26
Social Services
Housing 24 Has this person given birth to any children in
World War II (December 1941 to Decembe
.4{
S-1(2009)KFI, Page 9, Base (Black)
former employer or union (of this person or another family member) b. Insurance purchased directly from an insurance company (by this person or another family member) c. Medicare, for people 65 and older, or people with certain disabilities
office or shopping? Yes No
1 or 2 years 3 or 4 years 5 or more years
20 What is this Survey American Community persons marital status?
26 Has this person ever served on active duty in the

Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
d. Medicaid, Medical Assistance, or Population: any kind of government-assistance plan for those with low incomes or a disability e. TRICARE or other military health care f. VA (including those who have ever used or enrolled for VA health care) g. Indian Health Service h. Any other type of health insurance or health coverage plan Specify
Questions on Marital History

Widowed Divorced
Now married
U.S. Armed Forces, military Reserves, or Nationa Guard? Active duty does not include training for the
Questions as they appear in the questionnaire.

Never married SKIP to I Yes No
Separated
Yes, now on active duty Yes, on active duty during the last 12 months, but not now Yes, on active duty in the past, but not during the last 12 months No, training for Reserves or National Guard only SKIP to question 28a No, never served in the military SKIP to question 29a
21 In the PAST 12 MONTHS did this person get

a. Married? b. Widowed? c. Divorced?
27 When did this person serve on active duty in the
17 a. Is this person deaf or does he/she have

serious difficulty hearing? Yes No
22 How many times has this person been married?

Once Two times Three or more times
U.S. Armed Forces? Mark (X) a box for EACH period in which this person served, even if just for part of the period. September 2001 or later August 1990 to August 2001 (including Persian Gulf War) September 1980 to July 1990 May 1975 to August 1980 Vietnam era (August 1964 to April 1975) March 1961 to July 1964 February 1955 to February 1961 Korean War (July 1950 to January 1955) January 1947 to June 1950 November 1941 or earlier disability rating?
b. Is this person blind or does he/she have 23 In what year did this person last get married? serious difficulty seeing even when wearing glasses? Year Yes No
Source: ACS-1(2009)KFI 24 if this person is Answer question
Answer question 18a c if this person is 5 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.
female and 15 50 years old. Otherwise, SKIP to question 25a.
World War II (December 1941 to December 1946
18 a. Because of a physical, mental, or emotional

condition, does this person have serious difficulty concentrating, remembering, or making decisions? Yes
24 Has this person given birth to any children in

the past 12 months? Yes MEETING FEDERAL NEEDS No
28 a. Does this person have a VA service-connected
Yes (such as 0%, 10%, Marital history data enables 25 a. Does this personto more of his/her own measure the effects of federal20%, ... , 100%) multiple agencies have any accurately No SKIP to question 29a grandchildren under well-being of families. Adding measures No and state policies and programs that focus on the the age of 18 living in this Community Survey will provide estimates of marriage of maritalserious difficulty the Americanhouse or apartment? transitions to b. Does this person have b. What is this persons service-connected Yes walking orand divorce rates and duration, as well as flows into and out of marriage. This information is climbing stairs? disability rating? critical for more refined analyses of eligibility to question 26 services and benefits, and of changes No SKIP for program Yes 0 percent resulting from federal policies and programs. b. Is this grandparent currently responsible for No c. Does this person have and divorce data Marriage difficulty dressing or bathing? 30 or 40 percent will level to plan for 50 or 60 percent and assess state and community activities designed to influence marital and divorce behavior. Yes Equally important are tax and entitlement forecasting functions in a variety of federal programs Yes 70 percent or higher No including Medicare and Medicaid. No SKIP to question 26 most of the basic needs of any grandchild(ren) be under the age of 18 who live(s) in this house or used at the national, state, and sub-state apartment? 10 or 20 percent
.4{
ACS-1(2009)KFI, Page 9, Base (Black) ACS-1(2009)KFI, Page 9, Green Pantone 354 (10, 20, 40 and 50%)

Population: Questions on Marital History
COMMUNITY BENEFITS
Social Services Data will be used for formulation and assessment of Temporary Assistance for Needy Families (TANF) policies and programs at both the federal and state level. Data will be used to plan for and assess the success of grantees funded under the new Healthy Marriage grant program. Rates of marriage and divorce data are used to track and forecast changes in areas with large numbers of single-parent families, and thus identify needs for childcare, child support, and other social services. Government Marital history will permit analyses and projections of tax policies that can create or mitigate marriage penalties increased taxes for a married couple compared with what the same couple would pay if filing as unmarried individuals. Local governments use data about marital history in assessing needs for housing and other community development services under the Community Development Block Grant Evaluation.
www.census.gov
No
Three or more times
Is this person blind or does he/she have 23 In what year did this person last get married? serious difficulty seeing even when wearing glasses? Year Yes No
August 1990 to August 2001 (including Persian Gulf War) September 1980 to July 1990 May 1975 to August 1980 Vietnam era (August 1964 to April 1975) March 1961 to July 1964 February 1955 to February 1961 Korean War (July 1950 to January 1955) January 1947 to June 1950 November 1941 or earlier disability rating?

Population: Question on Fertility
nswer question 18a c if this person is years old or over. Otherwise, SKIP to e questions for Person 2 on page 12.
Question as it appears in the questionnaire.

24 Has this person given birth to any children in
the past 12 months? Yes No
Answer question 24 if this person is female and 15 50 years old. Otherwise, SKIP to question 25a.
World War II (December 1941 to Decembe
Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions? Yes No
28 a. Does this person have a VA service-conn

Yes (such as 0%, 10%, 20%, ... , 100%) No SKIP to question 29a b. What is this persons service-connected disability rating?
25 a. Does this person have any of his/her own

Yes No SKIP to question 26
Does this person have serious difficulty walking or climbing stairs? Yes No
grandchildren under the age of 18 living in this house or apartment?
0 percent b. Is this grandparent currently responsible for MEETING FEDERAL NEEDS 10 or 20 percent most of the basic needs of any grandchild(ren) Does this person have difficulty dressing or under the age of 18 who live(s) in this house or 30 or 40 percent The number of children born in the past 12 months is a measure of fertility that is used to bathing? apartment? project the future size of the population, a basic planning tool for agencies of the50 or 60 percent government. Yes 70 percent The U.S. Department of Health and Yes Human Services uses these data to carry out various or higher No No determining 26 programs required by statute, including SKIP to question the need for family planning services within the Indian Health Service, investigating matters on child welfare in the Childrens Bureau, and conducting research for voluntary family planning programs.
.4{
S-1(2009)KFI, Page 9, Base (Black)
COMMUNITY BENEFITS
Social Services Data about fertility are used to predict the number of children who will need adoptive homes under the Child Welfare Act. The Indian Health Service uses data about the number of babies born to determine the need for family planning services for its service-eligible population. Information about children born in the past 12 months is used in research on the family size of female adolescents and their actual birth rates in later life. The National Center for Health Statistics computes vital statistics for subnational areas using data about children born in the past 12 months.
www.census.gov
No
March 1961 to July 1964 to July 1964 March 1961 February 1955 to February 1961 February 1955 to February 1961 Korean War (July 1950 to (July 1950 to January 1955) Korean War January 1955) January 1947January 1947 to June 1950 to June 1950
I Answer question 24 question 24 if is person is I Answer if this person this nswer question 18a c if is person is female and 15 50 and 15 50 years old. Otherwise, ion 18a c if this person this female years old. Otherwise, years old or over. SKIP to over. Otherwise, Otherwise, SKIP to SKIP to question to question 25a. SKIP 25a. e questions2for Person 2 on page 12. for Person on page 12.
a physical, mental, or emotional emotional Because of a physical, mental, or the past 12 months? 12 months? the past does this person haveperson have serious condition, does this serious this person this a VA service-connected 28 a. Does28 a. Does haveperson have a VA service-con oncentrating, remembering, or difficulty concentrating, remembering, or Yes Yes disability rating? disability rating? cisions? decisions? making Question as it appears in the questionnaire. No No Yes (such as 0%, 10%, 20%, ... , 100%) Yes (such as 0%, 10%, 20%, ... , 100%) Yes this person this any of have any of 25 a. Does25 a. Does haveperson his/her own his/her own No SKIP toNo SKIP to question 29a question 29a grandchildren under the age of 18 living in 18 living in grandchildren under the age of No this house or apartment? apartment? this house or erson haveperson have serious difficulty Does this serious difficulty b. What is this What is this persons service-connected b. persons service-connected Yes Yes climbing stairs? walking or climbing stairs? disability rating? disability rating? No SKIP toNo SKIP to question 26 question 26 Yes 0 percent 0 percent b. Is this grandparentgrandparent currently responsible for b. Is this currently responsible for No 10 most of the basic of the basic needs of any grandchild(ren) 10 or 20 percent or 20 percent most needs of any grandchild(ren) erson haveperson have difficulty dressing under the age of 18 who live(s) in this house or Does this difficulty dressing or or under the age of 18 who live(s) in this house or30 or 40 percent or 40 percent 30 bathing? apartment? apartment? 50 or 60 percent or 60 percent 50 Yes Yes Yes 70 percent or 70 percent or higher higher No No SKIP toNo SKIP to question 26 13199096 question 26 c. How long has this grandparent been responsible for the(se) grandchild(ren)?
Population: Has this person givenGrandparentsany children in November 1941 or earlier or earlier 24 Question on personto any birth to in Caregivers 24 Has this birth given children as November 1941
World War II (December II (December 1941 to Decemb World War 1941 to December 1946)
4{if this person is .4{ nswer question 19
9
50%)
CS-1(2009)KFI, Page 9, Base (Black) )KFI, Page 9, Base (Black)
years old or over. Otherwise, SKIP to e questions for Person 2 on page 12.
If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparentGreen Pantone 354 (10, 20, 40 ACS-1(2009)KFI, Page 9, Green Pantone 354 (10, 20, 40 and 50%) and ACS-1(2009)KFI, Page 9, has been responsible for the longest period of time.
ecause of a physical, mental, or emotional ondition, does this person have difficulty oing errands alone such as visiting a doctors fice or shopping? Yes No
Less than 6 months 6 to 11 months 1 or 2 years 3 or 4 years 5 or more years

Source:Has this person ever served on active duty in the 26 ACS-1(2009)KFI
hat is this persons marital status? Now married Widowed Divorced Separated
Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the

Yes, now on active duty
This question was added to the American Community Survey in 1999 to comply with legislation Yes, on active duty during Never married SKIP to I the last that the but not now passed in the 104th Congress requiring12 months, decennial census program obtain information the PAST 12 MONTHS did this person getwho have primary responsibility for the care of their grandchildren. The Yes, on active duty in the past, but not about grandparents during the last 12 uses these data to distinguish households in Yes Department of Health and Human Services months U.S. No which a grandparent has primary No, training for Reserves child or children and also uses these data responsibility for a or National Guard Married? only SKIP to question 28a for the High Performance Bonus Awards Program under the Temporary Assistance to Needy No, never served in the military SKIP to Widowed? Families Program. question 29a
Divorced?
27 When did this person serve on active duty in the
ow many times has this person been married? Once Two times Three or more times
U.S. Armed Forces? Mark (X) a box for EACH period in which this person served, even if just for part of the period.
COMMUNITY BENEFITS
September 2001 or later
August 1990 to August 2001 (including Persian Gulf War) Daycare centers and other businesses use State and local governments, faith-based these data to develop new products and and other nonprofit organizations, and September 1980 to July 1990 what year did this person last get married?
Business
Government
ar
services for their communities. businesses use these data to plan, budget, May 1975 to August 1980 and pay benefits. Vietnam era (August 1964 to April 1975)
March 1961 to July 1964 February 1955 to February 1961 Korean War (July 1950 to January 1955) January 1947 to June 1950 World War II (December 1941 to December 1946) November 1941 or earlier
www.census.gov
nswer question 24 if this person is male and 15 50 years old. Otherwise, KIP to question 25a.
as this person given birth to any children in e past 12 months?
nce, or Now married son is sistance e, SKIP to omes Widowed page 12. Divorced
U.S. Armed Forces, military Reserves,Forces, military Reserves, or National U.S. Armed or National Now married c. How long has this grandparent been Active duty does notGuard? Active duty does not include training for the Guard? include training for the responsible for the(se) grandchild(ren)? National Guard, Reserves or National Guard, but DOES include Reserves or but DOES include Widowed
Separated health care
No, never served in the military SKIP to February 1955 to February 1961 February 1955 to February 1961 Answer question 24 ifIthisquestionquestion 24 if this person is Answer is person 29a this person is 50 years female and 15 50 years old. Otherwise, (July 1950 to January 1955) (July 1950 to January 1955) Korean the Korean War female and 15 Source:When didOtherwise, serve on active duty in War old. this 27 ACS-1(2009)KFI person wise, SKIP to Armed question 25a. SKIP to question 25a.U.S. SKIP toForces? Mark (X) a box for EACH period to June 1950 January 1947 to June 1950 January 1947 n been married? in which this person served, even if just for part of the on page 12. period. World War II (December 1941 to December 1946) World War II (December 1941 to December 1946) Has this person given24 Has any children in birth to any children in or earlier November 1941 or earlier birth to this person given November 1941 September months? ental, or emotional the past 12 months? the past 12 2001 or later son have serious August 1990 to August 2001 (includingthis person have a VA service-connected a VA service-connected 28 a. Does 28 a. Does this person have , remembering, or Persian Gulf War) Yes Yes disability rating? disability rating? September 1980 to July 1990 t get married? No No Yes (such as 0%, 10%, 20%, ... , 100%) as 0%, 10%, 20%, ... , 100%) Yes (such May his/her own a. Does this person have anyDoes this August 1980 any of his/her own 25 a. of1975 to person have MEETING FEDERAL NEEDS No grandchildren under theVietnam18 living under the Aprilof 18 living in to question 29a No SKIP to question 29a age of grandchildren in age 1975) SKIP Veteran status, era (August 1964 to including period this house or apartment? this house or apartment? of military service, is used primarily by the U.S. Department erious difficulty of Veterans Affairs to measure theWhat is thisveteransservice-connected the impact of veterans March 1961 to July 1964 b. needs of persons and to evaluate b. What is this persons service-connected Yes Yes rs? disability These programs dealing with education, disability rating?and health care. rating? data are needed to February 1955 to February 1961 employment, on is No SKIP to question 26 No SKIP toprogram planning, and budgeting for federal veterans programs and conduct Korean War (July 1950 to January 1955) policy analysis, question 26 0 percent 0 percent Otherwise, for reports to Congress on currently responsible for b. Is this grandparent currently responsible for1950 b. Is this 1947 to June state projections of veterans facilities and services. January grandparent 10 or 20 percent 10 or 20 percent most of the basic needs of any grandchild(ren) most of the basic needs of any grandchild(ren) fficulty dressing or 18 whoWorld Warthis house or1941live(s) in30 or 1946) or under the age of live(s) in II age of 18 who to December house under the (December this 40 percent 30 or 40 percent apartment? apartment? ny children in November 1941 or earlier 50 or 60 percent 50 or 60 percent Yes Yes 70 percent 70 percent or higher 28 a. Does this person have a VA service-connected or higher COMMUNITY BENEFITS No SKIP to question 26 No SKIP to question 26 disability rating?
on active duty Yes, on active duty Never or emotionalmarried SKIP to I Never married SKIP to I Yes,last 12 months, during now last 12 months, during nowsince 1930 ave ever asked the but not and Period but not Less than months Population: 6Questions on Veteran Status the 1840, 1890, 1910, e difficulty alth care) In the PAST 12 person get Yes, on active duty in the past, but not 21 In this person MONTHS did this Yes, on active duty in the past, but not iting a doctors MONTHS didthe PAST 12get 6 to 11 months during the last 12 months during the last 12 months of Military Service Yes No Yes No 1 or 2 years No, training for Reserves or National Guard Reserves or National Guard No, training for surance a. Married? a. Married? only SKIP to question 28a only SKIP to question 28a 3 or 4 years Specify No, never served in the military SKIP to No, never served b. Widowed? b. Widowed? years Questions as they appear in the questionnaire. in the military SKIP to 5 or more question 29a question 29a atus? c. Divorced? c. Divorced? on When did in the serve on active duty in the 26 Has this person ever served 27 active dutythis person 27 When did this person serve on active duty in the U.S. Armed Forces, military National a U.S. been married? U.S. Armed Forces? Mark How many times has 22 person been married?this personArmed person served, (X)which thisEACH period (X) a box for EACH period this How many times has Reserves, orthis Forces? Mark evenbox for person served, even if just for part of the in which in if just for part of the es he/she have Guard? Active duty does not include training for the period. period. Reserves or National Guard, but DOES include g? Once Once activation, for example, for the Persian Gulf War. September 2001 or later September 2001 or later Two times Two times Yes, now on active duty August 1990 to August 2001 August 1990 to August 2001 (including (including Three or more times Three or more times Persian Gulf War) Persian Gulf War) Yes, on active duty during the last year did this es he/she have this person what 12 married? person last get married? to July 1990 September 1980 to July 1990 In what year did 23 In last get months, but not now September 1980 even when wearing s person get Yes, on active duty in the past, but not May 1975 to August 1980 May 1975 to August 1980 Year Year the last 12 months during Vietnam April 1975) No, training for Reserves or National Guard era (August 1964 toVietnam era (August 1964 to April 1975) only SKIP to question 28a March 1961 to July 1964 March 1961 to July 1964
American Community VETERAN STATUS AND Survey PERIOD OF MILITARY SERVICE
If the grandparent is financially responsible for example, for the Persian Gulf War. activation, activation, for example, for the Persian Gulf War. Divorced more than one grandchild, answer the question for the grandchild for whom the grandparent hason active duty Yes, now Yes, now on active duty Separated been responsible for the longest period of time.
his/her own of 18 living in
For the Public Health Service Act, veteran status is used as one factor to determine 9 At state andSKIP to question 29a No county levels, veteran status the segments of the population who may is used for budgeting and program not be receiving needed medical services. planning for medical service-connected b. What is this persons services and nursing 9, Base (Black) home care forACS-1(2009)KFI, Page 9, (10, 20, 40 and 50%)(10, 20, 40 and 50%) ACS-1(2009)KFI, Page 9, Green Pantone 354 Green Pantone 354 disability rating? veterans. Social Yes (such as 0%, 10%, 20%, ... , 100%) Services
0 Department of Veterans Affairs The U.S. percent needs data about veteran status in 10 or 20 percent planning the locations and sizes of 30 or 40 percent veterans cemeteries. 50 or 60 percent 70 percent or higher
responsible for ny grandchild(ren) s) in this house or
Employment Data about veteran status are used to allocate funds to states and local areas for employment and job training programs for veterans.
www.census.gov
9
Page 9, Green Pantone 354 (10, 20, 40 and 50%)
n what year did this person last get married? Once ear Two times
period. September 1980 to July 1990
May 1975 to Augustlater September 2001 or 1980 Vietnam era (August 1964 to (including August 1990 to August 2001 April 1975) Three or more times Persian Gulf War) March 1961 to July 1964 September 1980 to July 1990 n what year did this person last get married? February 1955 to February 1961 nswer question 24 if this person is May 1975 to August 1980 ear Population: Question on VA Service-Connected Disability Korean War (July 1950 to January 1955) emale and 15 50 years old. Otherwise, Vietnam era (August 1964 to April 1975) KIP to question 25a. January 1947 to June 1950 March 1961 to July 1964 World War II (December 1941 to December 1946) February 1955 to February questionnaire. Question as it appears earlier 1961 as this question 24 ifbirth personchildren in person given this to any is November 1941 or in the nswer he past 12 months? Korean War (July 1950 to January 1955) emale and 15 50 years old. Otherwise, 28 a. Does this person have a VA service-connected KIP Yesquestion 25a. to January 1947 to June 1950 disability rating? World War II (December 1941 to December 1946) No Yes (such as 0%, 10%, 20%, ... , 100%) as this person given birth to any children in November 1941 or earlier . Does 12 person have any of his/her own he pastthismonths? No SKIP to question 29a grandchildren under the age of 18 living in 28 a. Does this person have a VA service-connected this house or apartment? Yes b. disability rating? What is this persons service-connected NoYes disability rating? Yes (such as 0%, 10%, 20%, ... , 100%) . Does No person have any 26 his/her own this SKIP to question of 0 percent No SKIP to question 29a grandchildren under the age of 18 living in . Is this grandparent currently responsible for this house or apartment? 10 or 20 percent most of the basic needs of any grandchild(ren) b. What30 or 40persons service-connected is this percent under the age of 18 who live(s) in this house or Yes disability rating? apartment? 50 or 60 percent No SKIP to question 26 0 percent Yes 70 percent or higher . Is this grandparent currently responsible for 10 or 20 percent most No the basic needs of26 grandchild(ren) of SKIP to question any under the age of 18 who live(s) in this house or 30 or 40 Source: ACS-1(2009)KFI percent apartment? 50 or 60 percent 9 Yes 70 percent or higher MEETING FEDERAL NEEDS
Rating
Veterans Affairs (VA) service-connected disability rating was added to the American Community ACS-1(2009)KFI, Page 9, Green Pantone 354 (10, 20, 40 and 50%) Survey (ACS) to enable the U.S. Department of Veterans Affairs to measure a veterans service9 connected disability compensation entitlement status. This information will improve the VAs ability to accurately anticipate the need for VA care and its associated cost.
ACS-1(2009)KFI, Page provide an annual report(10, 20, 40 and 50%) VA is required to 9, Green Pantone 354 to Congress that determines whether VA health care appropriations for the coming fiscal year are sufficient to cover expenditures associated with the expected demand for VA health care services. Adding the proposed service-connected disability status measure to the ACS will enable VA to make county-level estimates of veterans classified by income, service-connected status, and several other characteristics that are needed to classify enrollment priorities.
This information will fundamentally improve VAs capability to describe the total veteran population in terms of age, priority, and market area and to more accurately estimate the demand for VA care.
COMMUNITY BENEFITS
Health VA medical centers and their associated outpatient clinics would use these data to measure key determinants of the demand for VA care. Data on service-connected disability ratings would allow VA medical centers (and their regional networks) to engage in meaningful local area planning that accounts for expectations of the future demand for VA care.
www.census.gov
on do ANY work as one hour?
usually rode to work in the car, truck, or van LAST WEEK? Person(s)
37 LAST WEEK, could this person have started a

job if offered one, or returned to work if recalled? Yes, could have gone to work
n 35a
American Community SurveyNo, because of own temporary illness

33 What time did this person usually leave Labor Population: Questions on home
to go to work LAST WEEK? Hour Minute a.m.
erson work LAST
Force Status
days?
No, because of all other reasons (in school, etc.)
at more than one e worked most
38 When did this person last work, even for a few
reet name)
Within the past 12 months p.m. Person 1 (continued) appear in the questionnaire. Questions as they
continued)
nown, give a uch as the building or intersection. for pay is person work s)? ost office
34 a. LAST WEEK, did did it if you take this 29 How many minutes this32usuallymarked pay J Answer question person work for "Car,
person jobget from home to work LAST WEEK? at a to (or business)? truck, or van" in question 31. Otherwise, Minutes SKIP to question 33. Yes SKIP to question 30 No Did not work (or retired)
39 32
question 30
ork (or retired)
deperson do ANY work s the limits of that K little as one hour?
b. LAST WEEK, did this person do ANY work 32 How many people, including this person, forusually rode to work in the car, truck, or van pay, even for as little as one hour? Answer questions 35 38 if this person LAST WEEK? Yes did NOT work last week. Otherwise, Person(s) SKIP to No SKIP39a. question to question 35a
wn limits uestion 35a
orked at more than one or she worked most
his person work LAST
33 30 At what location did this person work LAST 35 a. LASTIfWEEK, was this person on layoff from WEEK? this person worked at more than one 33 job? time did this she worked most a What location, print where he orperson usually leave home
to go last week. to work LAST WEEK?
eign country nd street name)
Yes Hour SKIP to question 35c Minute a. Address (Number and street name) No a.m.
not known, give a ation such as the building treet or intersection.
p.m. b. LAST WEEK, was this person TEMPORARILY 34 absent from a job ornot known, give a If the exact address is business? description of the location such as the building nameYes, on vacation, temporary illness, or many minutes did it usually take this 34 How the nearest street or intersection. 40 person to get from home to work LAST WEEK? maternity leave, other family/personal b. Name of city,bad weather, etc. SKIP to reasons, town, or post office Minutes question 38
, or post office
y get to work LAST
used more than one ng the trip, mark (X) ost of the distance.
c. Is the work location inside the limits of that K c. Has this person been informed that he or she city or town? will be recalled to work within the next 6 months OR been given a date to return to n inside the limits of that K Answer questions 35 38 if this person Yes did work? NOT work last week. Otherwise, Motorcycle No, to question 39a. SKIP outside the city/town limits Yes SKIP to question 37 Bicycle 35 d. Name of county Walked city/town limits No Worked at 35 a. LAST WEEK, was this person on layoff from home SKIP Source: ACS-1(2009)KFI a job? to question 39a e. Name of U.S. state or foreign country Yes SKIP to question 35c Other method
No
or foreign country
Labor f. ZIP Code WEEK, was this person TEMPORARILYand unemploymentortemporary illness, force status is key to understanding work b. LAST 13 weeks less Yes, on vacation,patterns and the 40 During the PAST 12 M absent from Based on labor availability of workers. a job or business? market areas andmaternity leave, other levels, the U.S. unemployment family/personal WORKED, how many h reasons, bad weather, etc. SKIP to Department of Laboron vacation, temporary illness, Yes, identifies service delivery areas and determines amounts to be allocatedusually work each WE question 38 40 12 MONTHS, in the maternity The impact of immigration on During the PAST and job markets WEEKS leave, other to each for job training.bad weather, family/personal the economy is Usual hours worked eac WORKED, how question 36 did this person No SKIP to many hours reasons, etc. SKIP to usually work each WEEK? determined partially byusually get to work LAST this information is included in required reports 31 How did this question 38 person labor force data, and WEEK? this person usually used more than Green Pantone 354 (10,been informed 50%) or Act, The Office of question 36 Usual the worked each WEEK 0, Base (Black) to Congress.IfACS-1(2009)KFI, Page 10, one Budget, underhours Paperwork Reduction she c. Has this person 20, 40 and that he No SKIP to Management and method of transportation during the trip, mark (X) will be recalled to work within the next sually get to work uses data about employed most of the distance. of the criteria for defining metropolitan areas. The LAST the box of the one used for workers as part 6 conjunction given a date data, to develop ually used more than one Bureau of Economicperson been informed that he or she inmonths OR beenwith other to return to c. Has this Analysis uses this information, work? n during the trip, mark (X) Car, truck, or van toestimates used in the allocation formulas and eligibility criteria of Motorcycle will be recalled work within the next its for most of the distance.state per capita income 6 months date to Yes SKIP to question 37 Bus or trolley OR been given aBicycle return to many federalwork? bus such as Medicaid. programs
Motorcycle Bicycle Walked Worked at home SKIP to question 39a Other method
13199104 36 During the LAST 4 WE Answer question 32 SKIP to L 1 to 5 years ago if you marked "Car, ACTIVELY looking for truck, or van" in question 31. Otherwise, SKIP Over 5 years LAST 4never worked SKIP to been to question ago or WEEKS, has this person 36 questionthe 33. During 47 Yes ACTIVELY looking for work? No SKIP to ques a. During the PAST 12 MONTHS (52 weeks), did Yes this person workincluding this person, How manyNo SKIP to or more weeks? Count people, 50 question 38 paid rode to as work. usually time off work in the car, truck, or van 37 LAST WEEK, could thi LAST WEEK? job if offered one, or r Yes SKIP to question 40 recalled? Person(s) 37 LAST WEEK, could this person have started a No job if offered one, or returned to work if Yes, could have go recalled? b. How many weeks DID this person work, even No, because of ow for a few hours, including paidwork Yes, could have gone to vacation, paid No, because of all sick leave, and military service? What time No, because of own temporary illness did this person usually leave home to go to50 to 52 weeks work LAST WEEK? No, because of all other reasons (in school, etc.) 38 When did this person Hour 48 to 49 weeks Minute days? a.m. 40 to 47 weeks 38 When did this person p.m. work, even for a few last Within the past 12 days? 39 weeks 27 to 1 to 5 years ago 14 to 26 weekspast 12 months Within the Over 5 years ago o How manyweeks years ago SKIP to L this minutes did 13 1 to 5 or less it usually take question 47 person to get from home to work LAST WEEK? Over 5 years ago or never worked SKIP to Minutes 39 a. During the PAST 12 During thequestion 47 PAST 12 MONTHS, in the WEEKS this person work 50 WORKED, how many hours did this person usually work each WEEK?12 MONTHS (52 weeks), did paid time off as wo 39 a. During the PAST this person work 50 or Usual hours worked each WEEK more weeks? Count Yes SKIP to q paid time off as work. No Answer questions 35 38 if this person Yes SKIP to question 40 did NOT work last week. Otherwise, b. How many weeks D SKIP to question 39a. No for a few hours, inc sick leave, and mili b. How many weeks DID this person work, even for a few hours, including paid vacation, paid 50 to 52 weeks a. LAST sick leave, and military service? from WEEK, was this person on layoff a job? 48 to 49 weeks 50 to 52 weeks 40 to 47 weeks Yes SKIP to question 35c 48 to 49 weeks 27 to 39 weeks No 40 to 47 weeks 14 to 26 weeks 27 to 39 weeks b. LAST WEEK, was this person TEMPORARILY 13 weeks or les absent from a job or business? 14 to 26 weeks
y car
Streetcar or trolley car Walked Yes SKIP to question 37 Subway or elevated Worked at home SKIP Railroad No to question 39a Ferryboat Other method Taxicab
No
10

Population: Questions on Labor Force Status
COMMUNITY BENEFITS
Employment
For local areas with substantial unemployment, labor force data are used to allocate funds and identify programs that create new jobs. Data are used to target state and local areas with a labor force surplus for programs that promote business opportunities. Within the U.S. Department of Labor, data about the labor force are needed to evaluate job complaints reported on the basis of disability.
www.census.gov
J
29 a. LAST WEEK, did this person work for pay
at a job (or business)?
Answer question 32 if you marked "Car, truck, or van" in question 31. Otherwise, d. Name of county SKIP to question 33.
ACTIVELY looking w 35 a. LAST WEEK, fo
Yes SKIP American notto question 30 Community Surveye.many people, includingforeign country 32 How Name of U.S. state or this person, No Did work (or retired)
a job? Yes Yes to que No SKIP SKI No
Population: Questions on Place of Work and Journey to Work LAST WEEK?

b. LAST WEEK, did this person do ANY work for pay, even for as little as one hour? Yes No SKIP to question 35a as they appear in the questionnaire. Questions Person(s) f. ZIP Code
usually rode to work in the car, truck, or van
37 LAST WEEK, could th b. LAST WEEK, w job if offered one, or absent from a recalled?
30 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. a. Address (Number and street name)
33 What time did this person usually leave home 31 go to work LAST WEEK? to How did this person usually get to work LAST WEEK? If this person usually used more than one38 When did this person c. Has this person Hour methodMinute of transportation during the trip, mark (X)
the box of the one used for most of the distance. a.m.
Yes, on va Yes, could have g maternity reasons, b No, because of ow question 3 No, because of al No SKIP
Car, truck, or van Bus or trolley bus
p.m.
Motorcycle Bicycle
days? will be recalled 6 months OR b work? Within the past 1
1 to 5 years SKI Yes ago
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection. b. Name of city, town, or post office
Streetcar or trolley car Walked 34 How many minutes did it usually take this
at a job (or business)?
29 a. LAST WEEK, did this person work for pay

Yes SKIP to question 30 c. Is the work location inside the limits of that city or town? Did not work (or retired) No Yes b. LAST WEEK, did this person do ANY work for pay, even for as littlelimits hour? No, outside the city/town as one d. Name of Yes county No SKIP to question 35a
Over 5 No ago years question 47 person to get from home to work LAST WEEK? Subway or elevated Worked at home SKIP Minutes Railroad J Answer question 32 if you marked "Car, 39a 36 During the PAST 1 to question 39 a. During the LAST ACTIVELY lookin this person work 5 truck,Ferryboat in question 31. Otherwise, or van" paid time off as wo Other method SKIP to question 33. Yes Taxicab Yes SKIP to No SKIP to No Answer questions 35 38 if this person 32 How many last week. Otherwise, person, did NOT work people, including this usually rode 39a. b. LAST WEEK, coul 37 How many weeks SKIP to questionto work in the car, truck, or van 10 LAST WEEK? for a if offered one job few hours, in sick leave, and mil recalled? Person(s)
.4|%
35 a. LAST WEEK, was this person on layoff(Black) ACS-1(2009)KFI, Page 10, Base from
a job?
50 to 52 weeks Yes, could ha
48 to because No, 49 weeks
ACS-1(
30 Name of U.S. statedid foreign country LAST e. At what location or this person work
location, print where he or she worked most last week.
33 What time did this person usually leave home

No to go to work LAST WEEK?
Yes SKIP to question 35c
40 to because No, 47 weeks
27 to 39 weeks
WEEK? If this person worked at more than one
a. Address (Number and street name) f. ZIP Code
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection. Source: ACS-1(2009)KFI 31 How did this person usually get to work LAST WEEK? If this of city, usually or post office one b. Name person town, used more than
method of transportation during the trip, mark (X) the box of the one used for most of the distance.
No c.Busthetrolley bus Is or work location inside Bicycle the limits of that K Answer SKIP to question 37 this person Yes questions 35 38 if did NOT work last week. Otherwise, city or town? b. How many wee Streetcar or trolley car Walked No SKIP to question 39a. for a few hours Yes elevated Subway or Worked at sick leave, and home Basic knowledge about commutinglimits SKIPand the characteristics of commuter travel come patterns No, Railroad outside the city/town to question 39a 50 to 52 w from responses to these questions. The commuting data are WEEK, was this person on layoff from 35 a. LAST essential for planning highway Ferryboat d. Name of county Other method improvements and developing public transportation services, as well as for designing programs a job? 48 to 49 w Taxicab to ease traffic problems during peak periods, conserve energy, reduce pollution, and estimate 40 to 47 w Yes SKIP to question 35c and project the demand for alternative-fueled vehicles. These data are required to develop 27 to 39 w No standards e. Name of U.S. work-related vehicle trips and increasing passenger occupancy during for reducing state or foreign country 14 to 26 w peak periods of travel. The Bureau of Economic Analysis (BEA) plans to use county-level data in b. LAST WEEK, was this 10 gross commuting flows to develop place-of-residence earningsperson TEMPORARILY 13 weeks o computing estimates from placeabsent from a job or business?
Car, truck, or van
Motorcycle
14 to this per 38 When did26 weeks Hour Minute days? weeks or le b. LAST WEEK, was this person TEMPORARILY 13 a.m. absent from a job or business? Within the pa p.m. Yes, on vacation, temporary illness, 40 During theto 5 years a 1 PAST 12 maternity leave, other family/personal WORKED, how many reasons, bad weather, etc. SKIP to Over 5 years usually work each W question 38 34 How many minutes did it usually take this question 47 person to get from home to work LAST WEEK? Usual hours worked ea No SKIP to question 36 Minutes 39 a. During the PAS this person wo c. Has this person been informed that he or she paid time off a will be recalled to work within the next 6 months OR been given a date to return to Yes SKI work?
of-work estimates by industry. In addition, BEA also plans to use these data for state personal f. ZIP Code temporary illness, 40 During the PAST income estimates for determining federal fund allocations. Yes, on vacation,other family/personal maternity leave,
question 38 No SKIP to question 36 c. Has this person been informed that he or she will be recalled to work within the next 6 months OR been given a date to return to work? Yes SKIP to question 37
.4|%
ACS-1(2009)KFI, Page 10, Green Pantone 354 (10, m WORKED, how 2 reasons, bad weather, etc. SKIP to
usually work eac
Usual hours worke
31 How did this person usually get to work LAST

WEEK? If this person usually used more than one method of transportation during the trip, mark (X) the box of the one used for most of the distance. Car, truck, or van Bus or trolley bus Motorcycle Bicycle

Population: Questions on Place of Work and Journey to Work
COMMUNITY BENEFITS
Transportation These data form the database used by state departments of transportation and the more than 350 metropolitan planning organizations responsible for comprehensive transportation planning activities. Metropolitan planning organizations use these data to manage traffic congestion and develop strategies to mitigate congestion, such as carpooling programs and flexible work schedules. Public transit agencies use these data to plan for transit investments, identify areas needing better transit service, determine the most efficient routes, and plan for services for disabled persons. Emergency Preparedness Police and fire departments use data about where people work to plan emergency services in areas of high concentrations of employment. Employment Data are used to identify patterns of discrimination in hiring among minorities and other population groups within labor markets. Banking Financial institutions use data about commuting patterns and occupation to define market areas for describing lending practices and the effects of bank mergers.
www.census.gov
Yes, could have gone to work No, because of own temporary illness No, because of all other reasons (in school, etc.)
33 What time did this person usually leave home

to go to work LAST WEEK? Hour Minute
American Community Survey even for a few 38 When did this person last work,
a.m. Population: Questions on Work Status Last Year p.m. Within the past 12 months 1 to 5 years ago SKIP to L days?
Over 5 years ago or never worked SKIP to 34 How many minutes did it usually take this Questions as they appear in the questionnaire. question 47 person to get from home to work LAST WEEK? Minutes
ng
39 a. During the PAST 12 MONTHS (52 weeks), did

this person work 50 or more weeks? Count paid time off as work. Yes SKIP to question 40
that
Answer questions 35 38 if this person did NOT work last week. Otherwise, SKIP to question 39a.
No b. How many weeks DID this person work, even for a few hours, including paid vacation, paid sick leave, and military service? 50 to 52 weeks 48 to 49 weeks 40 to 47 weeks 27 to 39 weeks 14 to 26 weeks 13 weeks or less
35 a. LAST WEEK, was this person on layoff from

a job? Yes SKIP to question 35c No b. LAST WEEK, was this person TEMPORARILY absent from a job or business? Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. SKIP to question 38 No SKIP to question 36
40 During the PAST 12 MONTHS, in the WEEKS

WORKED, how many hours did this person usually work each WEEK? Usual hours worked each WEEK
AST
ne X) e.
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? Source: ACS-1(2009)KFI Yes SKIP to question 37 No
KIP n 39a
hod
To comply with provisions of the Civil Rights Act, the U.S. Department of Justice uses these data to determine the availability of individuals for work. Government agencies, in considering the programmatic and policy aspects of providing federal assistance to areas, have emphasized the requirements for reliable data to determine the employment resources available. Data about the number of weeks and hours worked last year are essential because these data allow the characterization of workers by full-time/part-time and full-year/part-year status. Data about working last year are also necessary for collecting accurate income data by defining the universe of persons who should have earnings as part of their total income.
k)
COMMUNITY BENEFITS
Employment
Under the Older Americans Act, these data are used to plan employment programs for the elderly. Researchers use these data to analyze differences between men and women or among various race or ethnic groups for individuals with similar weeks or hours worked. Companies use data on work status last year to make decisions on where to place new plants or offices. Data on work status last year are used for legal cases on discrimination under the Civil Rights Act.
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Answer questions 41 46 if this person worked in the past 5 years. Otherwise, SKIP to question 47. L Answer questions 41 46 if this person Population: Question on Class worked in the past 5 years. Otherwise, SKIP46 CURRENT47. MOST RECENT JOB 41 to question OR Questions on Industry ACTIVITY. Describe clearly this persons chief
45 What kind of work or business, or of an individual, for company was this person doing? 45 What kind of work was charitable organization? tax-exempt, or this person doing?
accountant)
an employee of a PRIVATE FOR-PROFIT
(For example: registered nurse, personnel American Community Survey aoflocal GOVERNMENTsecretary,manager, supervisor order department, employee
(For example: registered nurse, personnel manager, wages, salary, or commissions? supervisor of order department, secretary, accountant) employee of a PRIVATE NOT-FOR-PROFIT, an
of Worker(city, county, etc.)?
Mark (X) the "Yes" box d. Social Security orand g person received, Railr TOTAL AMOUNT durin (NOTE: The "past 12 m Yes date $ todays one Railr d. Social Security oryear a No Mark (X) the TOTAL AM "No" box 12 $ NOT received. Yes
46 What were this persons most important
a state GOVERNMENT employee?
Questions on Occupation
41
job activity or business last week. If this person had more than one job, describe the one at 41 46 CURRENT OR MOST RECENT JOB which this person worked the most hours. If this person had no job or business last week, give ACTIVITY. Describe clearly this persons chief information for his/her last week. If this person job activity or business last job or business. had more than one job, describe the one at which this person worked the most hours. If this Was this person or Questions as they person had no job business last week, give Mark (X) ONE box. information for his/her last job or business.
business, professional practice, or 46 What were this persons most important farm?
activities a Federal GOVERNMENT employee? or duties? (For example: patient care, directing hiring policies, supervising order clerks, SELF-EMPLOYED in own NOT INCORPORATED typing and filing, reconciling financial records) activities or duties? (For example: patient care, SELF-EMPLOYED in own order clerks, directing hiring policies, supervisingINCORPORATED typing andbusiness, professional practice, or farm? filing, reconciling financial records)
No If net income was a los e. SupplementalTOTAL AM Security the right of the dollar a 12
working WITHOUT appear in the questionnaire.PAY in family business or farm? 47 INCOME IN THE PAST 12 MONTHS
For Yes received jo income $ share for each person e. Supplemental Security No report the whole amou TOTAL AM mark the "No" box for t 12 $ Yes a. Wages, salary, com No f. Any or tips from all jobo public assistance TOTAL AM 12 fromdeductions or local w the state for taxes
an person of a PRIVATE 41 Was thisemployeebusiness, or ofFOR-PROFIT for company or an individual, Mark (X) ONE box. wages, salary, or commissions? an employee of a PRIVATE FOR-PROFIT NOT-FOR-PROFIT, company or or charitable of an individual, for tax-exempt, business, or organization? wages, salary, or commissions? a local GOVERNMENT employee an employee etc.)? (city, county, of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or charitable organization? a state GOVERNMENT employee? a local GOVERNMENT employee a Federal GOVERNMENT employee? (city, county, etc.)? SELF-EMPLOYED in own NOT INCORPORATED a state GOVERNMENT employee? business, professional practice, or farm? a Federal GOVERNMENT employee? SELF-EMPLOYED in own INCORPORATED SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm? business, professional practice, or farm? working WITHOUT PAY in family business SELF-EMPLOYED in own INCORPORATED or farm? business, professional practice, or farm? 42 For whom did this person work? business working WITHOUT PAY in family or farm? If now on active duty in the Armed Forces, mark (X) this box Source: ACS-1(2009)KFI personArmed Forces. 42 For whom did this of the work? and print the branch
42 For whom did this persontype of income this Mark (X) the "Yes" box for each work?
If AMOUNT during the 47 INCOME INon active duty in PAST 12 MONTHS. TOTALnow THE PAST 12 MONTHS person received, and give your best estimate of the
the Armed Forces, mark is this box from (NOTE: The "past 12 months" (X)the period Markand the one year agoof the type of Forces. this (X) print the box for each Armed income todays date "Yes" branch up through today.) person received, and give your best estimate of the Name of company, business, or other employer TOTAL AMOUNT during the PAST 12 of income Mark (X) the "No" box to show types MONTHS. No (NOTE: The "past 12 months" is the period from g. Retirement, survivor, o TOTAL AM b. Self-employment i NOT received. todays date one year ago up through today.) Do NOT include Social 12 Se businesses or farm proprietorships an If net income was a loss, mark the "Loss" box to Mark (X) of the dollar amount. types of income the "No" box to show NET income after bu the right g. Retirement, survivor, o Yes $ NOT received. 43 What kind of business or industry was this? Do NOT include Social Se For income received jointly,the locationappropriate Describe the activity at report the where employed. No If net(For example:a loss, mark the "Loss" box to mail Yes $ A TOTAL share income was hospital, if thats not publishing, for each person or, newspaper possible, the right ofhouse,amount for only one person bank) 12 order the dollar engine report the whole autoamount.manufacturing, and Yes $ No mark the "No" box for the other person. TOT For income received jointly, report the appropriate No h. Any other sources of in TOTAL A share for each person or, if thats not possible, 12 a. Wages,whole amount for only one person and regularly such as Veter report the salary, commissions, bonuses, or the from all jobs. Report amount unemployment compen mark tips"No" box for the other person. before c. Interest, dividends deductions for taxes, bonds, dues, or other items. or alimony. Do NOT inclu h. such royalty income, or Any other sources of in Is this mainly Mark (X) ONE box. as money from an e 44Wages, salary, commissions, bonuses, and trusts. Reportin a. regularly such as Veter home. an account. to or tips from all jobs. Report amount before unemployment compen .00 Yes $ manufacturing? deductions for taxes, bonds, ,dues, or other items. or alimony. Do NOT inclu No such as money$ $an in wholesale trade? Yes Yes from TOTAL AMOUNT for past home. 12 months retail $ .00 Yes trade? No No If now of company, business, or other employer Name on active duty in , TOTAL A TOT the Armed Forces, mark (X) this box other (agriculture, construction, service, No 12 Yes $ b. Self-employment income from for past TOTAL AMOUNT own nonfarm government, etc.)? and print the branch of the Armed Forces. 12 months businesses or farm businesses, including No Name of company, business, or other employer proprietorships and partnerships. Report TOTAL A 48 What was this persons to NET income after business expenses. PAST 12 MONTHS? Add 12 en b. Self-employment incomethis personnonfarm What kind of work was from own doing? d. Social any losses. 45 to 47h; subtractSecurity or IR 43 What kind of business or industry was this? businesses or farm businesses, including (For example: registered nurse, personnel manager, enter the amount and mark ( Describe the activity at the location where employed. proprietorships anddepartment, secretary, supervisor of$ order partnerships. Report What was this persons to .00 48 the dollar amount. Yes (For example: hospital, newspaper publishing, mail , accountant) NET income after business expenses. PAST 12 MONTHS? Add en $ Yes order house, auto engine 41 46 if this person Answer questions manufacturing, bank) No L to 47h; subtract any losses. I Loss 43 What kind of business or industry was this? TOTAL AMOUNT for past worked in the at the location Otherwise, enterNone OR $ and mark ( the amount No Describe the activity past 5 years. where employed. 12 months , TOTA .00 Yes $ the dollar amount. (For SKIP to question newspaper publishing, mail example: hospital, 47. , order house, auto engine manufacturing, bank) No TOTAL A Loss c. ACS-1(2009)KFI, Page 11, Base (Black) Interest, dividends, net rental income, TOTAL AMOUNT for past ACS-1(20 12 None OR $ 12 months royalty income, or income from estates , e. Supplemental Secu What were this even small amounts credited 46and trusts. Reportpersons most important 41 46 CURRENT OR MOST 44 Is this mainly Mark (X) ONE box. RECENT JOB activities or duties? (For example: ACTIVITY. Describe clearly this persons chief TOTAL A todirecting hiring policies, supervising patient care, an account. order job activity or business last week. If this person c. Interest, dividends, net rental income, clerks, manufacturing? $ 12 Yes typing and filing, reconciling financial records) had more than one job, describe the one at royalty income, or income from estates which this person worked box. wholesale Mark 44 Is this mainly trade?(X) ONE the most hours. If this and trusts. Report even small amounts credited No .00 Yes $ person had no job or business last week, give TOTA , to an account. retail trade? information for his/her last job or business. manufacturing? No Loss TOTAL AMOUNT for past other (agriculture, wholesale trade? construction, service, 12 months .00 Yes $ 41 Was this person government, etc.)? f. Any public assistan , Mark (X) ONE box. retail trade? 47 INCOME IN THE PAST 12 MONTHS from the state or lo No Loss TOTAL AMOUNT for past Continue with the questio other (agriculture, of a PRIVATE FOR-PROFIT construction, service, 12 months an employee Mark (X) the "Yes" box for each type of income this next page. If only 1 person government, etc.)? company or business, or of an individual, for Yes for $ person received, and give your best estimate of the SKIP to page 28 mailin TOTAL AMOUNT during the PAST American labor These questionswages, salary,the work activity and occupational experience of the12 MONTHS. Continue with the questio describe or commissions? No (NOTE: The "past 12 months" is the period from TOTA an employee of a PRIVATE NOT-FOR-PROFIT, next page. If only 1 person force. Data are used to formulate organization? programs for date one year ago up through today.) policy and todays employment, career development tax-exempt, or charitable SKIP to page 28 for mailin and training, and to measure compliance with antidiscrimination policies. Mandated reports Mark (X) the "No" box to show types of income local GOVERNMENT employee g. Retirement, surviv for Congress on athe county, etc.)? rely on the analysis of these characteristics. The Bureau of NOT received. (city, labor force Do NOT Soci Economic Analysis uses Pageinformation, in conjunction with other data, to developGreen Pantone 354 include20, ACS-1(2009)KFI, this 11, Base (Black) ACS-1(2009)KFI, Page 11, its state per (10, a state GOVERNMENT employee? If net income was a loss, mark the "Loss" box to capita income estimates used in the allocation formulas rightforthe dollar amount. the or of eligibility criteria in many federal Yes $ a Federal GOVERNMENT employee? programs such as Medicaid and plans to use the county-level information to develop its county ACS-1(2009)KFI, Page in own NOT INCORPORATED 11, Base (Black) ACS-1(2009)KFI, Page 11, Green For income received jointly, report the appropriate Pantone 354 (10, 20, No SELF-EMPLOYED and state per capita income estimates.or farm? TOTA share for each person or, if thats not possible, business, professional practice, report the whole amount for only one person and mark the "No" box for the other person. SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm? h. Any other sources a. Wages, salary, commissions, bonuses, regularly such as V working WITHOUT PAY in family business or tips from all jobs. Report amount before unemployment com or farm? deductions for taxes, bonds, dues, or other items. or alimony. Do NOT such as money from 42 For whom did this person work? home. $ .00 Yes If now on active duty in ,
f. Any public assistance o Yes $ Yes $ from the state or local w No No TOTAL AM TOT 12 $ Yes
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Population: Question on Class of Worker Questions on Industry Questions on Occupation
COMMUNITY BENEFITS
Employment Information about industry, occupation, and class of worker is important for creating jobs as companies use these data to decide where to locate new plants, stores, or offices. Agencies use these data to plan jobtraining programs for seniors. Federal agencies use these data in litigation where employment discrimination is alleged. Social Services Data are used to estimate the demand for staff in health care occupations and their geographic distribution based on these data.
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on 1 (continued)
on 1 (continued)
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13199112 13199112 TOTAL AMOUNT for past 12 months d. Social Security or Railroad Retirement. 45 What kind of work was this person doing? work was this d. Social Security or Railroad Retirement. 45 What kind of registered nurse,person doing? (For example: registered nurse, personnel manager, (For example: personnel manager, e. Supplemental Security Income (SSI). What were this persons most important 46 supervisor of order department, secretary, OR MOST RECENT JOB supervisor of order department, secretary, accountant) duties? (For example: patient care, $ activities or .00 Yes clearly if this person accountant) $ .00 Yes 41 46this persons chief Population: Questions on Income , 41last week. If this person directing hiring policies, supervising order clerks, ss 46 if this person , $ .00 Yes 5 years. Otherwise, No typing and filing, reconciling financial records) ob, years. Otherwise, 5 describe the one at No , TOTAL AMOUNT for past orked the most hours. If this TOTAL AMOUNT for past 7. 7. No 12 months business last week, give TOTAL 12 monthsfor past AMOUNT 13199112 er last job or business. 12 months Questions as they appear in the questionnaire. (SSI). e. Supplemental Security Income (SSI). 46 What were this persons most important OR MOST RECENT JOB e. Supplemental Security Income 46 What were this persons most important OR MOST RECENT JOB activities or duties? (For example: patient care, f. Any public assistance or welfare payments clearly this persons chief activities or duties? (For example: patient care, clearly this persons chief d. Social Security or Railroad Retirement. 45 hiring policies, supervising order clerks, directingWhat kind of work was this person doing? ss last week. If this person 47 directing(For THE PAST supervising order clerks, manager, from Yes $ local welfare office. INCOMEhiring policies, 12 MONTHS personnel IN example: registered nurse, the state or ss last week. If this person .00 typing and filing, reconciling financial records) $ .00 ob, describe the one at Yes typing and filing, reconcilingdepartment, secretary, , ob, describe the one at supervisor of order financial records) , f a PRIVATE FOR-PROFIT orked the most hours. If this Mark (X)accountant) for each type of income this the "Yes" box orked the most hours. If this No $ .00 No Yes AMOUNT for past 13199112 business last week, give siness, 41 week,this person $ Yes TOTAL AMOUNT for past person received, and give your best estimate of the estionsor lastan individual, for business of 46 if give , .00 TOTAL er last job or business. or commissions? 12 ,months er last job or business. TOTAL AMOUNT during the PAST 12 MONTHS. the past 5 years. Otherwise, 12 months No No TOTAL AMOUNT (NOTE: The "past 12 months" is the period from TOTAL AMOUNT for past for past estion 47. NOT-FOR-PROFIT, f a PRIVATE 12 todays date one year agothis through doing? up person today.) 12 months months charitable organization? f. Any public assistance or welfare payments d. Any public assistance or welfare payments 45 What kind of work was f. Social Security or Railroad Retirement. registered nurse, personnel 47 (For example:"No"PAST 12 MONTHSof income from the state or local welfare office. 47 INCOMEthe THE PAST 12 MONTHS manager, INCOME IN THE box to show types IN order department, secretary, from the state or local welfare office. Mark (X) NMENT employee supervisor of e. Supplemental Security Income (SSI). g. Retirement, survivor, or disability pensions. 46 the RRENT OR MOST RECENT JOB NOT received. were this persons most important accountant) "Yes" box for each type of income this fc.)? a Mark (X)What .00 Yes fDescribeif this person a PRIVATE FOR-PROFIT Mark (X)activities box for each type of income this care, the "Yes" or duties? Do NOT include$ Social Security. 41 PRIVATE FOR-PROFIT forchief 46orclearly individual, this persons , siness, of an individual, of an $ .00 Yes person received, and give your(For example: patient best estimateorder clerks, of the siness, or Otherwise, thisfor $ .00 Yes person received, and givemark the "Loss" box to directing a loss, your best estimate or business last week. If person , NMENT employee? 5 commissions? years. If net income was hiring policies, supervising of the No or commissions? , TOTAL AMOUNT during the PAST 12financial records) .00 Yes AMOUNT for past or TOTAL AMOUNT during reconciling MONTHS. an describe the TOTAL $ No the right typing and filing,the PAST 12 MONTHS. of the dollar amount.is the period from , 7. one job,employee? one at No .00 Yes $ ERNMENT NOT-FOR-PROFIT,If this (NOTE: The "past 12 months" is the period from TOTAL 12 monthsfor past erson hours. (NOTE: The "past 12 months" f a PRIVATE NOT-FOR-PROFIT, PRIVATE TOTAL AMOUNT for past AMOUNT No f a job worked the mostweek, give , todays date one year ago up through today.) 12 months no or business last todays datereceived jointly, report the today.) charitable organization? TOTAL AMOUNT for past 12 months For income one year ago up through appropriate charitable NOTjob or business. No ED in own organization? for his/her last INCORPORATED 12 months TOTAL AMOUNT for past share (X) the "No" box or, if thats not possible, for each person to show types of income ssional practice, or farm? Mark e. Supplemental Security Income (SSI). NMENT employee Mark were "No"amount show types of income box to for only one person 12 months 46 What(X) thethis persons most important and OR MOST RECENT JOB NMENT employee report the whole g. Retirement, survivor, or disability pensions. NOT received. g. Retirement, survivor, or disability pensions. c.)? NOT received. box for the example: patient care, activities or duties? (For other person. clearly ersonown INCORPORATED c.)? mark the "No" ED in this persons chief Do NOT include Social Security. or welfare payments f. Any public assistance Do NOT include Social Security. directing hiring policies, supervising order clerks, ssbox. week. If this person E last ssional employee? .00 Yes the state or local welfare 47and filing, reconciling financial records) to INCOME a loss, mark the "Loss" box PAST 12 MONTHS from $ NMENT practice, or farm? If net income was IN THEmark the "Loss" box to h. Any other sources of income received office. typing ob, describe the one at NMENT employee? If net income was a loss, , the right of the dollar amount. a. Wages, salary, commissions, bonuses, orkedPAY most hours. If this the right Mark (X) the "Yes" box for each type of income this regularly $ as Veterans (VA) payments, of the dollar amount. .00 OUT the inemployee?FOR-PROFIT family business No $ Yes such ERNMENTlast week, give ployee of aemployee? PRIVATE .00 Yes ERNMENT business or tips from all jobs. Report amount before unemployment compensation, child support TOTAL AMOUNT any or job or business.an individual, forFordeductions for taxes, bonds,give yourother estimate of the or alimony. Do NOT include, lump sum payments $ , .00 Yes 12 monthsfor past person received, and dues, or best items. er in business, or of income received jointly, report the appropriate No EDlastown NOT INCORPORATED For income received jointly, report the appropriate , past No ED in own NOT INCORPORATED , salary, or commissions? AMOUNT TOTAL inheritance or share forTOTALperson or,during the PAST 12 MONTHS. each person or, if thats not possible, such as money from an AMOUNT for pastsale of a ssional work? or farm? practice, or farm? TOTAL AMOUNT for the share for(NOTE: The "past 12 months" is the period from each if thats not possible, No ssional person practice, 12 months report the whole amount for only one person and amount person home. TOTAL AMOUNT for past 12 months ployee of a PRIVATE NOT-FOR-PROFIT, report the wholedate one for only one throughand f. Any public assistance or welfare payments 12 months mark thetodays $ for the year ago up "No" other person. .00 today.) ED empt, or charitable organization? y inin own INCORPORATED mark theYes box for the other person. "No" box ED in own INCORPORATED , 47 INCOME IN THE PAST 12 MONTHS from the state or local welfare office. ssional practice, or farm? mark (X) practice, or farm? ssional this box No (X) the "No" box to show types of income h. Any other sources of income received h. Any other sources of income received .00 Mark Yes $ GOVERNMENT employee a. Wages, salary, TOTAL AMOUNT for income this regularly such as Veterans (VA) payments,pensions. f of PRIVATE FOR-PROFIT a the Armed Forces. , g. Retirement, survivor, or disability Mark (X)NOT"Yes" commissions, bonuses, the received. for12 months of past box each type a. Wages, salary, commissions, bonuses, regularly such as Veterans (VA) payments, OUT PAY in family business ounty, etc.)? an individual, OUT PAY in family businessfor or tips from all jobs. Reportbest estimate of the amount before unemployment include Social Security.support siness, oror other employer of $ compensation, child No Do NOT compensation, child support .00 Yes person received,all jobs. Report amount before or tips from and give your unemployment business, , deductions for taxes, bonds, dues, or other items. or alimony. Do TOTAL AMOUNT for past or commissions?employee? TOTAL AMOUNT taxes, bonds, dues, or other items. deductions for during the loss, mark the "Loss" box to or alimony. Do NOT include lump sum payments NOT include lump sum payments GOVERNMENT If net income was a PAST 12 MONTHS. 12 months No such as money TOTAL AMOUNT for past sale of a (NOTE: The "past of the dollaris the periodnonfarm 12 months" amount. from b. Self-employment income from own such as money from an$ from an inheritance or the sale of a inheritance or the the right 13199112 person work? fral PRIVATE NOT-FOR-PROFIT, a GOVERNMENT employee? .00 person work? Yes 12 months home. todays date one $farm businesses, including businesses oryear ago up through today.) home. , charitable organization? Yes $ .00 Yes income received jointly, report.00 y in proprietorships and partnerships. Report appropriate For the , 48 What was this persons total income during the y in No EMPLOYED in own NOT INCORPORATED ,types of income mark professional practice, or farm? Mark (X)No "No" eachto show or, if thats not possible, PAST 12 MONTHS? Add entries in questionsfor past the NET incomefor box person TOTAL AMOUNT 47a share after business expenses. NMENT this box mark (X) employee ess, (X) this box .00 No Yes $ g. Retirement, survivor, ornet income pensions. .00 Yes $ losses. If disability Retirement. 12 months of or Armed Forces. NOT received. kind of work was this person doing? andto 47h; subtract anySecurity or ,Railroadwas a loss, d. Social report whole AMOUNT only one 45 What the TOTAL amount forfor past person c.)?the Armed Forces. TOTAL AMOUNT for past essthe industry was this? of , 12 months enter NOT amount and mark (X) the (For example: registered nurse, personnel manager, DotheNoinclude Social Security. "Loss" box next to 12 months mark the "No" box for the other person. at the location where employed. EMPLOYED in ownemployer INCORPORATED No business, or other employer $aof order department, secretary, .00to Yes was loss, mark the "Loss" box the dollar amount. TOTAL AMOUNT for past supervisor TOTAL AMOUNT for past business, or other NMENT employee? If net income al, newspaper publishing, mail ess, professional practice, or farm? h. Any other sources of income received accountant) 12 months gine manufacturing, bank) $ the rightNo the dollar income , of b. Self-employment amount. from own nonfarm own nonfarm $ .00 .00 estions 41 46 if this Yes Yes 12 months, a. Wages, salary, commissions, bonuses, regularly such as Veterans (VA) payments, ERNMENT employee? person b. Self-employment income from for past Loss ng WITHOUT PAY in family business TOTAL AMOUNT including before , businesses or farm businesses, including or tips from all jobs. Report amount unemployment compensation,.00 support child the past 5 years. Otherwise, None OR $ No businesses or farm businesses, appropriate Forproprietorships and partnerships. Report income received jointly, report the m? in own NOT INCORPORATED 12 months No or alimony. Do NOT include lump the ED , TOTAL, AMOUNT for deductions for taxes, bonds, Report items. proprietorships and partnerships. dues, or estion 47. TOTAL AMOUNT for during the 48 What was this persons total income during past share for each person or, if thats not possible,other48 What was this persons total income past sum payments ssional practice, or farm? 12questions 47aLoss of a months or the sale NET income after business expenses. PAST 12 MONTHS? Add 12 months such as TOTAL entries in money from an inheritance NET income after business expenses. PAST 12 MONTHS? Add entries in questions 47a report the whole amount for only one person and did this person work? to 47h; subtract any losses.AMOUNT for past a loss, If net income was home. ess or industry was this? c. Interest, dividends, net rental income, to 47h; subtract any losses.12 net income was a loss, If months mark the "No" box for the$ ess or industry was this? ED in own INCORPORATED .00 enter the amount and mark (X) the "Loss" box next to Yesor income from estates other person. at the location where employed. enter the amount and mark (X) the "Loss" box next to royalty income, ctive duty in where employed. at the location or farm? , .00 ssional OR MOST RECENT JOB practice, $ this persons most important e. Supplemental Security Income Yes Report theAny other sources of income received (SSI). What $ h. dollar amount. 46 trusts. were even small amounts credited al,(X) ONE box. this box mail RRENTmark (X) .00 k newspaper publishing, mail Yes No the dollar amount. and al, newspaper publishing, Forces, , , gine manufacturing, bank) activities Yes Veterans (VA) payments, .00 a. to an account. commissions, bonuses, patient care, Wages, salary, or duties? (For AMOUNT for past regularly such as $ Describe of the this persons gine manufacturing, bank) TOTAL example: No e branch clearlyArmed Forces. OUT PAY in family business chief , No directing hiring policies, supervising or business last week. If this person or tips from allTOTALReport amountpast order clerks, jobs. AMOUNT for past before Loss unemployment compensation, child support ? 12 months Loss $ AMOUNT financial records) .00 .00 None OR $ Yes include lump sum payments typing andTOTAL reconcilingfor other items. filing, 12 months or an one job, describe the one at $ No , deductions for taxes, bonds, dues, orNone OR Do NOT alimony. mpany, business, or other employer , , TOTAL AMOUNT .00 past for 12 months , , e? erson worked the most hours. If this such as money from an inheritance months of a .00 Yes $ No 12 or the sale Loss Loss person work? no job or business last week, give , b. Self-employment income from own nonfarm home. TOTAL AMOUNT for past TOTAL AMOUNT for past TOTAL AMOUNT for past for his/her last job or business. c. Interest, dividends,or farm businesses, including No businesses net rental income, .00 12 Yes $ 12 monthsmonths c. Interest, dividends, net rental income, y in 12 months TOTAL AMOUNT for past , from estates Loss royalty income, or income partnerships. proprietorships and ure, (X) this box 48 What was this persons total income during the royalty income, or income from estates Report markconstruction, service, 12 months No NET income after business expenses. k (X) ONE box. and trusts. Report even small amounts credited $ .00 k (X) Armed Yes 12 MONTHS? Add entries in questions 47a c.)?the PAST public assistance or welfare payments ersonONE box. Forces. and trusts. Report even small amounts credited TOTAL AMOUNT for past of f. Any , to an account. to 47h; subtract any losses. If net income was a loss, to an account. IN THE 12 months of business or industry was 47 INCOME PAST 12 MONTHS local welfare office. No from the state or mark (X) the "Loss" box next to ?E box. or other employer this? enter the amount and ? business, e activity at the location where employed. TOTAL AMOUNT for past Continue with the questions for Person 2 on the Source: ACS-1(2009)KFI $ .00 Yes the dollar amount. e: 12 is listed ployee of a PRIVATE FOR-PROFIT e? hospital, newspaper publishing, mail next page. If only 1 person months on page 2, Mark the , .00 e? Yes (X)$ "Yes" box for each type of income this $ .00 , auto engine manufacturing, bank) forb. Self-employment income from own nonfarm Yes received, and give your best estimate of the any or business, or of an individual, $ .00 , SKIP to page 28Yes for mailing instructions. person No , AMOUNT for businesses or farm businesses, including past Loss , TOTAL , salary, or commissions? No TOTAL AMOUNT during the PAST 12 Loss No None OR $ proprietorships and partnerships. Report MONTHS. What was this persons total income during the .00 No TOTAL AMOUNT for past period from 12 months Loss 48 , , TOTAL AMOUNT for (NOTE: The "past 12 months" past 12 expenses. ure, construction, service, TOTAL AMOUNT for past ployee of a PRIVATE NOT-FOR-PROFIT, NET income after business months is the ure, construction, service, PAST 12 MONTHS? Add entries in questions 47a 12 months Loss c.)? todays date one year ago up through today.) c.)? empt, or charitable organization? to 47h; subtract any losses. If net income was a loss,11 TOTAL12 months for past AMOUNT ess or industry was this? c. Interest, dividends, net rental income, enter the amount and mark (X) the "Loss" box next to 12 months at the location where employed. Mark the .00 Yes (X)$ income, orto show types of income the dollar amount. questions for Person 2 on the GOVERNMENT employee royalty "No" box income from estates Continue with the questions for Person 2 on the al, newspaper publishing, mail Continue with the1 person is listed on page 2,pensions. g. If disability , NOT received. Report even small amounts credited nly manufacturing, bank) ounty, etc.)? and trusts. next page. Retirement, survivor, or on page 2, gine Mark (X) ONE box. next page.Doonly 1 person is listed If only include Social Security. NOT No to an account. Loss SKIP to page 28 for mailing instructions. Page 11, Base (Black) ACS-1(2009)KFI, Page 11, Green Pantone 354 (10,mailing instructions. 20, 40 and 50%) TOTAL AMOUNT for past .00 GOVERNMENT employee? If net income was12 loss, mark the "Loss" box to SKIP to page 28 for a months None OR $ acturing? , , the right of the dollar amount. $ .00 Yes ral trade? Loss saleGOVERNMENT employee? .00 Yes $ TOTAL AMOUNT for ,past 11 , 11 For dividends, net jointly, report the c. Interest, income receivedrental income, appropriate No EMPLOYED in own NOT INCORPORATED rade? 12 months No TOTAL AMOUNT used royalty income, or person or, if thats not past circumstances. Income data are for past to Income measure of TOTAL AMOUNT for general economic ess, professional practice, or farm? is a vitalshare for each incomefrom estates possible,Loss 12 months k (X) ONE box. agriculture, construction, service, report the whole amount for only one person and and trusts. Report even small amounts credited 12 months determine to an account. "No" to measure economic well-being, and to assess the need for nment, etc.)? mark the EMPLOYED in own INCORPORATED poverty status, box for the other person. Page 11, Base (Black) ACS-1(2009)KFI, Page 11, Green Pantone 354 (10, 20, 40 and 50%) ? Page 11, Base (Black) ess, professional practice, or farm? assistance. TheseACS-1(2009)KFI, Page 11, Green Pantone 354 other 20, 40 of income received data are included in federal allocation formulas for many50%) Any (10, sources and government Continue with the questions for Person 2 on the h. regularly such as Veterans (VA) payments, a. Wages, bonuses, e? Yes $ salary, commissions,.00 ng WITHOUT PAY in family business programs. next page. If only 1 person is listed on page 2, or tips from all jobs. Report amount before unemployment compensation, child support , m? SKIP alimony.28 for mailing instructions. or to page Do NOT include lump sum payments No deductions for taxes, bonds, dues, or other items. Loss TOTAL AMOUNT for past such as money from an inheritance or the sale of a ure, construction,work? did this person service, 12 months home. c.)? .00 Yes $ 11 ctive duty in , Forces, mark (X) this box No Continue with the questions for Person 2 on the $ .00 Yes TOTAL AMOUNT for past e branch of the Armed Forces. , next page. If only 1 person is listed on page 2, 12 months SKIP to page 28No mailing instructions. mpany, business,11, Base (Black) or other employer 09)KFI, Page ACS-1(2009)KFI, Page 11, Green Pantonefor 354 (10, 20, 40 and 50%) TOTAL AMOUNT for past 12 months b. Self-employment income from own nonfarm businesses or farm businesses, including 11 proprietorships and partnerships. Report 48 What was this persons total income during the NET income after business expenses. PAST 12 MONTHS? Add entries in questions 47a No ,
41 46 if this person 5 years. Otherwise, 7.
(For example: registered nurse, personnel manager, supervisor of order department, secretary, accountant)
Yes
.00
(continued)
(continued)
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Population: Questions on Income
COMMUNITY BENEFITS
Social Services Under the Older Americans Act, funds for food, health care, and legal services are distributed to local agencies based on data about elderly people with low incomes. Data about income at the state and county levels are used to allocate funds for food, health care, and classes in meal planning to low-income women with children. Employment Income data are used to identify local areas eligible for grants to stimulate economic recovery, run job-training programs, and define areas such as empowerment or enterprise zones. Education Data about poor children are used to allocate funds to counties and school districts. These funds provide resources and services to improve the education of economically disadvantaged children. Housing Under the Low-Income Home Energy Assistance Program, income data are used to allocate funds to areas for home energy aid. Under the Community Development Block Grant Program, funding for housing assistance and other community development is based on income and other decennial census data.
www.census.gov

Population 09

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Population 09

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American Community Survey

form and return after receiving

StartQuestions as they appear in the questionnaire. Here

Please print todays date. Month Day Year

mation about g or staying at ng label and ment, or mobile dress on the

Area Code + Number

ave questions s form, please call elephone call is free.

(TDD): ne call is free.

abla espaol y cuestionario, 33-5625. stionario en por telfono paol.

1 What is Person 2s name?

merican site at:

2 How is this person related

OMB No. 0607-0810

What is Person 1s name?

Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law

3 What is Person 2s sex? Ma

Please report babies as age 0 Print

NOTE: Please answer BOTH Question 5 about Hispanic origin and 5

NOTE: Please answer BO

Question 6 about race. For

No, not of Hispanic, Latino Yes, Puerto Rican Yes, Cuban

Yes, Mexican, Mexican Am

American Community Survey

2 How is this person related to Person 1? Mark (X) ONE box.

Source: ACS-1(2009)KFI 3 What is Person

2s sex? Mark (X) ONE box.

, Hispanic origins are not races.

5 about Hispanic origin and rigin

origin Print origin, for example, araguan, Salvadoran, Spaniard,

Some other race Print race.

2 How is this per

American Community Survey

Biological so First Name MI

Population: Question on Sex

Please report bab

Yes, another Argentinean, and so on.

Asian Indian Chinese Filipino

Social Vietnamese Services

Other Asian for example, Laotian, Thai Cambodian,

.4{6 policies and practices under the housing

ACS-1(2009)KFI, Page 2, Base (Black)

Biological son or daugh

What is Person 1s name?

Adopted son or daught Brother or sister Father or mother Grandchild Parent-in-law

American Community Survey

What is Person 1s sex? Mark (X) ONE box.

Question as it Female appears in the questionnaire. Male

3 What is Person 2s sex?

4 What is Person 2s age a

Please report babies as ag Pr

Source: ACS-1(2009)KFI 6 Question

NOTE: Please answer BOTH Question 5 about Hispanic origin and

NOTE: Please answer

Question 6 about race.

MEETING FEDERAL NEEDS

No, not of Hispanic, La

Yes, Mexican, Mexican

6 What is Person 2s race

Black, African Am., or N

American Indian or Ala

Asian Indian Chinese Filipino

Cambodian, and so on.

Some other race Prin