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13179015 DC U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU THE Puerto Rico Community Survey This booklet shows the content of the Puerto Rico Community Survey questionnaire. IN This form asks for information about the people who are living or staying at the address on the mailing label and about the house, apartment, or mobile home located at the address on the mailing label. AT FO R M IO ➜ Please print today’s date. Month Day Year Please print the name and telephone number of the person who is filling out this form. We may contact you if there is a question. Last Name First Name N Please complete this form and return it as soon as possible after receiving it in the mail. Start Here ➜ AL C O PY MI Area Code + Number — If you need help or have questions about completing this form, please call 1-800-717-7381. The telephone call is free. Telephone Device for the Deaf (TDD): Call 1-800-786-9448. The telephone call is free. ¿NECESITA AYUDA? Si usted habla español y necesita ayuda para completar su cuestionario, llame sin cargo alguno al 1-800-814-8385. For more information about the Puerto Rico Community Survey, visit our web site at: http://www.census.gov/acs/www/ ➜ How many people are living or staying at this address? ● INCLUDE everyone who is living or staying here for more than 2 months. ● INCLUDE yourself if you are living here for more than 2 months. ● INCLUDE anyone else staying here who does not have another place to stay, even if they are here for 2 months or less. ● DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment. Number of people ➜ Fill out pages 2, 3, and 4 for everyone, including yourself, who is living or staying at this address for more than 2 months. Then complete the rest of the form. USCENSUSBUREAU FORM (06-16-2008) ACS-1(INFO)(2009)PR KFI OMB No. 0607-0810 §.2{0¤ 13179023 Person 1 1 What is Person 2’s name? (Person 1 is the person living or staying here in whose name this house or apartment is owned, being bought, or rented. If there is no such person, start with the name of any adult living or staying here.) Last Name (Please print) Person 2 First Name MI 2 How is this person related to Person 1? Mark (X) ONE box. Husband or wife Biological son or daughter Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Foster child Other nonrelative 1 What is Person 1’s name? Last Name (Please print) First Name MI Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother 2 How is this person related to Person 1? X Person 1 Grandchild Parent-in-law 3 4 What is Person 1’s sex? Mark (X) ONE box. Male Female 3 What is Person 2’s sex? Mark (X) ONE box. Male Age (in years) Month Day Year of birth Age (in years) C O What is Person 1’s age and what is Person 1’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. 4 What is Person 2’s age and what is Person 2’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Month Day Year of birth ➜ 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 IO N Question 6 about race. For this survey, Hispanic origins are not races. ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 2 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban M AT White Black, African Am., or Negro IN 6 FO R Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. What is Person 1’s race? Mark (X) one or more boxes. 6 What is Person 2’s race? Mark (X) one or more boxes. White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. American Indian or Alaska Native — Print name of enrolled or principal tribe. Asian Indian Chinese Filipino Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Japanese Korean Vietnamese AL Question 6 about race. For this survey, Hispanic origins are not races. Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. PY Female Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. Asian Indian Chinese Filipino Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. Some other race – Print race. Some other race – Print race. 2 §.2{8¤ 13179031 Person 3 1 What is Person 3’s name? Last Name (Please print) First Name MI Person 4 1 What is Person 4’s name? Last Name (Please print) First Name MI 2 How is this person related to Person 1? Mark (X) ONE box. Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Foster child Other nonrelative 2 How is this person related to Person 1? Mark (X) ONE box. Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Foster child Other nonrelative 3 4 What is Person 3’s sex? Mark (X) ONE box. Male Female 3 What is Person 4’s sex? Mark (X) ONE box. Male Age (in years) Month Day Year of birth Age (in years) C O What is Person 3’s age and what is Person 3’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. 4 What is Person 4’s age and what is Person 4’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Month Day Year of birth ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 3 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban IO N Question 6 about race. For this survey, Hispanic origins are not races. ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 4 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban M AT IN 6 FO R Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. What is Person 3’s race? Mark (X) one or more boxes. White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. 6 What is Person 4’s race? Mark (X) one or more boxes. White Black, African Am., or Negro American Indian or Alaska Native — Print name of enrolled or principal tribe. Asian Indian Chinese Filipino Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Japanese Korean Vietnamese AL Question 6 about race. For this survey, Hispanic origins are not races. Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. PY Female Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. Asian Indian Chinese Filipino Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. Some other race – Print race. Some other race – Print race. §.2{@¤ 3 13179049 Person 5 1 What is Person 5’s name? Last Name (Please print) First Name MI ➜ If there are more than five people living or staying here, print their names in the spaces for Person 6 through Person 12. We may call you for more information about them. Person 6 Last Name (Please print) First Name MI 2 How is this person related to Person 1? Mark (X) ONE box. Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Foster child Other nonrelative Sex Male Female Age (in years) Person 7 Last Name (Please print) First Name MI 3 4 What is Person 5’s sex? Mark (X) ONE box. Male Female Sex Male Female Age (in years) Person 8 Age (in years) Month Day Year of birth AL Sex C Male O What is Person 5’s age and what is Person 5’s date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Last Name (Please print) PY First Name MI Female ➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and 5 Is Person 5 of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican Yes, Cuban Age (in years) N Question 6 about race. For this survey, Hispanic origins are not races. Person 9 AT IO Last Name (Please print) First Name MI M Sex Male Female Age (in years) R Yes, another Hispanic, Latino, or Spanish origin – Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. Person 10 Last Name (Please print) First Name MI White Black, African Am., or Negro IN 6 What is Person 5’s race? Mark (X) one or more boxes. FO Sex Male Female Age (in years) American Indian or Alaska Native — Print name of enrolled or principal tribe. Person 11 Last Name (Please print) First Name MI Asian Indian Chinese Filipino Other Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander – Print race, for example, Fijian, Tongan, and so on. Sex Male Female Age (in years) Person 12 Last Name (Please print) First Name MI Some other race – Print race. Sex Male Female Age (in years) 4 §.2{R¤ 13179056 Housing ➜ Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label. Which best describes this building? Include all apartments, flats, etc., even if vacant. A mobile home A one-family house detached from any other house A one-family house attached to one or more houses A building with 2 apartments A building with 3 or 4 apartments A building with 5 to 9 apartments A building with 10 to 19 apartments A building with 20 to 49 apartments A building with 50 or more apartments Boat, RV, van, etc. A Answer questions 4 – 6 if this is a HOUSE OR A MOBILE HOME; otherwise, SKIP to question 7a. 8 Does this house, apartment, or mobile home have – a. hot and cold running water? b. a flush toilet? Yes No 1 4 How many cuerdas is this house or mobile home on? Less than 1 cuerda ➔ SKIP to question 6 1 to 9.9 cuerdas 10 or more cuerdas c. a bathtub or shower? d. a sink with a faucet? e. a stove or range? f. a refrigerator? 5 IN THE PAST 12 MONTHS, what C AL N None $1 to $999 $1,000 to $2,499 $2,500 to $4,999 $5,000 to $9,999 $10,000 or more O were the actual sales of all agricultural products from this property? PY g. telephone service from which you can both make and receive calls? Include cell phones. 9 How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household? None 1 2 3 4 5 6 or more 2 About when was this building first built? 2000 or later – Specify year 6 Is there a business (such as a store or 1990 to 1999 1980 to 1989 1970 to 1979 1960 to 1969 1950 to 1959 1940 to 1949 1939 or earlier FO R M Yes No barber shop) or a medical office on this property? AT IO 10 Which FUEL is used MOST for heating this house, apartment, or mobile home? Gas: from underground pipes serving the neighborhood Gas: bottled, tank, or LP Electricity Fuel oil, kerosene, etc. Coal or coke Wood Solar energy Other fuel No fuel used house, apartment, or mobile home? Rooms must be separated by built-in archways or walls that extend out at least 6 inches and go from floor to ceiling. • INCLUDE bedrooms, kitchens, etc. • EXCLUDE bathrooms, porches, balconies, foyers, halls, or unfinished basements. Number of rooms 7 a. How many separate rooms are in this 3 When did PERSON 1 (listed on page 2) move into this house, apartment, or mobile home? Month Year IN b. How many of these rooms are bedrooms? Count as bedrooms those rooms you would list if this house, apartment, or mobile home were for sale or rent. If this is an efficiency/studio apartment, print "0". Number of bedrooms §.2{Y¤ 5 13179064 Housing (continued) 11 a. LAST MONTH, what was the cost of electricity for this house, apartment, or mobile home? Last month’s cost – Dollars $ , OR Included in rent or condominium fee No charge or electricity not used b. LAST MONTH, what was the cost of gas for this house, apartment, or mobile home? Last month’s cost – Dollars $ , OR Included in rent or condominium fee Included in electricity payment entered above No charge or gas not used No c. IN THE PAST 12 MONTHS, what was the cost of water and sewer for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost. Past 12 months’ cost – Dollars $ , OR Included in rent or condominium fee No charge .00 $ , OR None .00 .00 .00 12 IN THE PAST 12 MONTHS, did anyone in this household receive Nutritional Assistance Program benefits or a Nutritional Assistance Program benefit card? Yes No C Answer questions 16 – 20 if you or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to E on the next page. 13 Is this house, apartment, or mobile home part of a condominium? Yes ➔ What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box. Monthly amount – Dollars 16 About how much do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale? Amount – Dollars $ , , .00 O C PY 17 What are the annual real estate taxes on THIS property? Annual amount – Dollars $ , OR None .00 14 Is this house, apartment, or mobile home – Owned by you or someone in this household with a mortgage or loan? Include home equity loans. IO Mark (X) ONE box. N AL $ AT 18 What is the annual payment for fire, hazard, and flood insurance on THIS property? Annual amount – Dollars , OR None .00 FO B $ d. IN THE PAST 12 MONTHS, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost. Past 12 months’ cost – Dollars $ , OR Included in rent or condominium fee No charge or these fuels not used .00 IN Answer questions 15a and b if this house, apartment, or mobile home is RENTED. Otherwise, SKIP to question 16. 15 a. What is the monthly rent for this house, apartment, or mobile home? Monthly amount – Dollars , .00 b. Does the monthly rent include any meals? Yes No 6 §.2{a¤ R Owned by you or someone in this household free and clear (without a mortgage or loan)? Rented? Occupied without payment of rent? ➔ SKIP to C M 13179072 Housing (continued) 19 a. Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property? Yes, mortgage, deed of trust, or similar debt Yes, contract to purchase No ➔ SKIP to question 20a 20 a. Do you or any member of this household have a second mortgage or a home equity loan on THIS property? Yes, home equity loan Yes, second mortgage Yes, second mortgage and home equity loan No ➔ SKIP to D b. How much is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property? E Answer questions about PERSON 1 on the next page if you listed at least one person on page 2. Otherwise, SKIP to page 28 for the mailing instructions. b. How much is the regular monthly mortgage payment on THIS property? Include payment only on FIRST mortgage or contract to purchase. Monthly amount – Dollars $ , OR No regular payment required ➔ SKIP to question 20a c. Does the regular monthly mortgage payment include payments for real estate taxes on THIS property? Yes, taxes included in mortgage payment No, taxes paid separately or taxes not required d. Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property? .00 $ , OR .00 No regular payment required D 21 What are the total annual costs for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site? Exclude real estate taxes. Annual costs – Dollars $ , .00 §.2{i¤ IN Yes, insurance included in mortgage payment No, insurance paid separately or no insurance FO R M AT IO Answer question 21 if this is a MOBILE HOME. Otherwise, SKIP to E . N AL C O PY Monthly amount – Dollars 7 13179080 Person 1 ➜ Please copy the name of Person 1 from page 2, then continue answering questions below. Last Name 11 What is the highest degree or level of school this person has COMPLETED? Mark (X) ONE box. If currently enrolled, mark the previous grade or highest degree received. NO SCHOOLING COMPLETED 13 What is this person’s ancestry or ethnic origin? No schooling completed First Name MI NURSERY OR PRESCHOOL THROUGH GRADE 12 Nursery school Kindergarten Grade 1 through 11 – Specify grade 1 – 11 (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 English at home? Yes No ➔ SKIP to question 15a 7 Where was this person born? In the United States – Print name of state. Outside the United States – Print Puerto Rico or name of foreign country, or U.S. Virgin Islands, Guam, etc. 12th grade – NO DIPLOMA HIGH SCHOOL GRADUATE b. What is this language? Regular high school diploma COLLEGE OR SOME COLLEGE 8 Is this person a citizen of the United States? Yes, born in the Puerto Rico ➔ SKIP to 10a Yes, born in a U.S. state, District of Columbia, 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 PY GED or alternative credential For example: Korean, Italian, Spanish, Vietnamese c. How well does this person speak English? Very well Well Not well Not at all Associate’s degree (for example: AA, AS) Bachelor’s degree (for example: BA, BS) AFTER BACHELOR’S DEGREE AL C 1 or more years of college credit, no degree O Some college credit, but less than 1 year of college credit 15 a. Did this person live in this house or apartment 1 year ago? Person is under 1 year old ➔ SKIP to question 16 Yes, this house ➔ SKIP to question 16 No, outside Puerto Rico and the United States – Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then SKIP to question 16. No, not a U.S. citizen 9 FO 10 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. R F Answer question 12 if this person has a bachelor’s degree or higher. Otherwise, SKIP to question 13. M When did this person come to live in Puerto Rico? Print numbers in boxes. Year Doctorate degree (for example: PhD, EdD) AT IO Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) N No, different house in Puerto Rico or the United States b. Where did this person live 1 year ago? Address Development or condominium name Number and street name No, has not attended in the last 3 months ➔ SKIP to question 11 Yes, public school, public college IN 12 This question focuses on this person’s Yes, private school, private college, home school b. What grade or level was this person attending? Mark (X) ONE box. Nursery school, preschool Kindergarten Grade 1 through 12 – Specify grade 1 – 12 BACHELOR’S DEGREE. Please print below the specific major(s) of any BACHELOR’S DEGREES this person has received. (For example: chemical engineering, elementary teacher education, organizational psychology) Name of city, town, or post office Name of municipio in Puerto Rico or U.S. county College undergraduate years (freshman to senior) Graduate or professional school beyond a bachelor’s degree (for example: MA or PhD program, or medical or law school) Enter Puerto Rico or name of U.S. state ZIP Code 8 §.2{q¤ 13179098 Person 1 (continued) 16 Is this person CURRENTLY covered by any of the H 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)? If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time. following types of health insurance or health coverage plans? Mark "Yes" or "No" for EACH type of coverage in items a – h. 19 Because of a physical, mental, or emotional Yes No condition, does this person have difficulty a. Insurance through a current or doing errands alone such as visiting a doctor’s former employer or union (of this office or shopping? person or another family member) b. Insurance purchased directly from Yes an insurance company (by this No person or another family member) c. Medicare, for people 65 and older, or people with certain disabilities d. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability e. TRICARE or other military health care 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 Less than 6 months 6 to 11 months 1 or 2 years 3 or 4 years 5 or more years 20 What is this person’s marital status? Now married Widowed Divorced Separated Never married ➔ SKIP to I Yes a. Married? b. Widowed? c. Divorced? No 26 Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War. Yes, now on active duty 21 In the PAST 12 MONTHS did this person get – PY 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 AL C IO N O 27 When did this person serve on active duty in the U.S. Armed Forces? Mark (X) a box for EACH period in which this person served, even if just for part of the period. 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 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 World War II (December 1941 to December 1946) November 1941 or earlier G IN Answer question 18a – c if this person is 5 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12. 18 a. Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions? Yes No b. Does this person have serious difficulty walking or climbing stairs? Yes No c. Does this person have difficulty dressing or bathing? Yes No FO I No 24 Has this person given birth to any children in the past 12 months? Yes No R Answer question 24 if this person is female and 15 – 50 years old. Otherwise, SKIP to question 25a. Yes M 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 AT Three or more times 28 a. Does this person have a VA service-connected disability rating? Yes (such as 0%, 10%, 20%, ... , 100%) No ➔ SKIP to question 29a b. What is this person’s service-connected disability rating? 0 percent 10 or 20 percent 30 or 40 percent 50 or 60 percent 70 percent or higher 25 a. Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment? Yes No ➔ SKIP to question 26 b. Is this grandparent currently responsible for most of the basic needs of any grandchild(ren) under the age of 18 who live(s) in this house or apartment? Yes No ➔ SKIP to question 26 §.2{¥¤ 9 13179106 Person 1 (continued) 29 a. LAST WEEK, did this person work for pay at a job (or business)? Yes ➔ SKIP to question 30 No – Did not work (or retired) b. LAST WEEK, did this person do ANY work for pay, even for as little as one hour? Yes No ➔ SKIP to question 35a J Answer question 32 if you marked "Car, truck, or van" in question 31. Otherwise, SKIP to question 33. 36 During the LAST 4 WEEKS, has this person been ACTIVELY looking for work? Yes No ➔ SKIP to question 38 32 How many people, including this person, 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 No, because of own temporary illness No, because of all other reasons (in school, etc.) 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 Development or condominium name Number and street name 33 What time did this person usually leave home to go to work LAST WEEK? Hour Minute 38 When did this person last work, even for a few a.m. p.m. days? Within the past 12 months : PY 1 to 5 years ago ➔ SKIP to L Over 5 years ago or never worked ➔ SKIP to question 47 34 How many minutes did it usually take this C AL N AT IO Yes ➔ SKIP to question 35c No Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. ➔ SKIP to question 38 No ➔ SKIP to question 36 Yes ➔ SKIP to question 37 No 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 Minutes O person to get from home to work LAST WEEK? 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 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 c. Is the work location inside the limits of that city or town? Yes No, outside the city/town limits d. Name of municipio in Puerto Rico or U.S. county K Answer questions 35 – 38 if this person did NOT work last week. Otherwise, SKIP to question 39a. 35 a. LAST WEEK, was this person on layoff from e. Enter Puerto Rico or name of U.S. state or foreign country IN FO b. LAST WEEK, was this person TEMPORARILY absent from a job or business? R M a job? 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 f. ZIP Code 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 Carro público Subway or elevated Railroad Ferryboat Taxicab Motorcycle Bicycle Walked Worked at home ➔ SKIP to question 39a Other method 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? 10 §.2|’¤ 13179114 Person 1 (continued) L Answer questions 41 – 46 if this person worked in the past 5 years. Otherwise, SKIP to question 47. 45 What kind of work was this person doing? d. Social Security or Railroad Retirement. Yes ➔ No $ (For example: registered nurse, personnel manager, supervisor of order department, secretary, accountant) , .00 TOTAL AMOUNT for past 12 months 41 – 46 CURRENT OR MOST RECENT JOB ACTIVITY. Describe clearly this person’s chief job activity or business last week. If this person had more than one job, describe the one at which this person worked the most hours. If this person had no job or business last week, give information for his/her last job or business. 46 What were this person’s most important e. Supplemental Security Income (SSI). Yes ➔ No $ activities or duties? (For example: patient care, directing hiring policies, supervising order clerks, typing and filing, reconciling financial records) , .00 TOTAL AMOUNT for past 12 months 41 Was this person – Mark (X) ONE box. an employee of a PRIVATE FOR-PROFIT company or business, or of an individual, for wages, salary, or commissions? an employee of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or charitable organization? a local GOVERNMENT employee (city, county, municipio, etc.)? a state GOVERNMENT employee? a Federal GOVERNMENT employee? SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm? SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm? working WITHOUT PAY in family business or farm? 47 INCOME IN THE PAST 12 MONTHS. Mark (X) the "Yes" box for each type of income this person received, and give your best estimate of the TOTAL AMOUNT during the PAST 12 MONTHS. (NOTE: The "past 12 months" is the period from today’s date one year ago up through today.) f. Any public assistance or welfare payments from the state or local welfare office. Yes ➔ No $ , .00 PY TOTAL AMOUNT for past 12 months O Mark (X) the "No" box to show types of income NOT received. If net income was a loss, mark the "Loss" box to the right of the dollar amount. For income received jointly, report the appropriate share for each person – or, if that’s not possible, report the whole amount for only one person and mark the "No" box for the other person. C g. Retirement, survivor, or disability pensions. Do NOT include Social Security. Yes ➔ No $ AL , .00 IO N TOTAL AMOUNT for past 12 months 42 For whom did this person work? If now on active duty in the Armed Forces, mark (X) this box ➔ and print the branch of the Armed Forces. Name of company, business, or other employer M Yes ➔ No AT a. Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items. $ , .00 h. Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support or alimony. Do NOT include lump sum payments such as money from an inheritance or the sale of a home. Yes ➔ No $ IN FO R TOTAL AMOUNT for past 12 months , .00 TOTAL AMOUNT for past 12 months b. Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships. Report 48 What was this person’s total income during the NET income after business expenses. PAST 12 MONTHS? Add entries in questions 47a Yes ➔ No $ 43 What kind of business or industry was this? Describe the activity at the location where employed. (For example: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank) , .00 to 47h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount. TOTAL AMOUNT for past 12 months Loss None OR $ , , .00 Loss 44 Is this mainly – Mark (X) ONE box. manufacturing? wholesale trade? retail trade? other (agriculture, construction, service, government, etc.)? c. Interest, dividends, net rental income, royalty income, or income from estates and trusts. Report even small amounts credited to an account. Yes ➔ No $ TOTAL AMOUNT for past 12 months , .00 TOTAL AMOUNT for past 12 months Loss ➜ Continue with the questions for Person 2 on the next page. If only 1 person is listed on page 2, SKIP to page 28 for mailing instructions. §.2|/¤ 11 13179122 Person 2 The balance of the questionnaire has questions for Person 2, Person 3, Person 4, and Person 5. The questions are the same as the questions for Person 1. 12 §.2|7¤ IN FO R M AT IO N AL C O PY §.2}g¤ IN FO R M AT IO N AL C O PY 13179270 27 13179288 Mailing Instructions ➜ Please make sure you have... • listed all names and answered the questions on pages 2, 3, and 4 • answered all Housing questions • answered all Person questions for each person. ➜ Then... IN FO R M Thank you for participating in the Puerto Rico Community Survey. AT • make sure the barcode above your address shows in the window of the return envelope. IO N • put the completed questionnaire into the postage-paid return envelope. If the envelope has been misplaced, please mail the questionnaire to: U.S. Census Bureau P.O. Box 5240 Jeffersonville, IN 47199-5240 AL The Census Bureau estimates that, for the average household, this form will take 38 minutes to complete, including the time for reviewing the instructions and answers. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 0607-0810, U.S. Census Bureau, 4600 Silver Hill Road, AMSD – 3K138, Washington, D.C. 20233. You may e-mail comments to Paperwork@census.gov; use "Paperwork Project 0607-0810" as the subject. Please DO NOT RETURN your questionnaire to this address. Use the enclosed preaddressed envelope to return your completed questionnaire. Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget. This 8-digit number appears in the bottom right on the front cover of this form. Form ACS-1(INFO)(2008)PR KFI (06-16-2008) For Census Bureau Use POP EDIT PHONE JIC1 JIC2 EDIT CLERK TELEPHONE CLERK JIC3 JIC4 28 §.2}y¤ C O PY