OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU TM 2020 Census of American Samoa Individual Census Questionnaire American Samoa FOR NPC USE ONLY This is your Individual Census Questionnaire for the 2020 Census of American Samoa. It is important that everyone be counted, regardless of where they may be living at the time of the census. This Individual Census Questionnaire is to be used to count people who were living, staying or receiving services in group quarters on April 1, 2020. Some examples of group quarters include college or university residence halls, nursing homes, group homes, residential treatment centers, workers’ group living quarters and correctional facilities. Please answer ALL of the questions on this questionnaire. Then follow the instructions you were given when you received this questionnaire in order to return it to the appropriate person. You are required by law to respond to the census (Title 13, U.S. Code, Sections 141, 193, 221 and 223). BCU Map Spot 11810017 D UHE BCU UHE Map Spot Within Map Spot ID UHE Within Map Spot ID FOR OFFICIAL USE ONLY The Census Bureau estimates that completing the questionnaire will take 25 minutes on average. Send comments regarding this burden estimate or any other aspect of this burden to: Paperwork Reduction Project xxxx-xxxx, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments to <2020.census.paperwork@census.gov>. Use “Paperwork Reduction Project xxxx-xxxx” as the subject. Group Quarters ID A. PN This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit approval number that appears at the upper right of the questionnaire confirms this approval. If this number were not displayed, we could not conduct the census. B. Answered By: C. QC: D. JIC1 FORM Respondent Group Quarters Administrator Observation (TNSOLs only) Other Rework JIC2 D-Q-GE-AS (11-20-2018) Draft 17 §,r!2¤ County R AF Census Office T Please turn to page 2 to begin. Use a blue or black pen. Start here 1. ➜ NOTE: Please answer BOTH Question 6 about Hispanic origin and Question 7 about race. For this census, Hispanic origin is not a race. What is your name? Print name below. 6. Last Name(s) Are you of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican Am., Chicano First Name MI Yes, Puerto Rican Yes, Cuban 2. Do you live or stay here most of the time? Yes 3. Yes, another Hispanic, Latino, or Spanish origin – Print, for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. C No Besides here, what is the full address of a place where you sometimes live or stay? 7. I never stay at any other place. I only live here. What is your race? Mark K J one or more boxes AND print origins. I White – Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. C T Address Number (For example: 5007) Street Name (For example: N Maple Ave) R AF Black or African Am. – Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C Apt/Unit (For example: Apt A or Lot 3) Physical Description (if applicable) D Village/Municipality/Estate ZIP Code 5. Vietnamese Native Hawaiian Filipino Korean Samoan Asian Indian Japanese Chamorro Other Asian – Print, for example, Pakistani, Cambodian, Hmong, etc. C Are you male or female? Mark K J ONE box. I Male Chinese Other Pacific Islander – Print, for example, Tongan, Fijian, Marshallese, etc. C Some other race – Print race or origin. C Female What is your age on April 1, 2020, and what is your date of birth? If you don’t know the exact age, please estimate. For babies less than 1 year old, do not write the age in months. Write 0 as the age. Age on April 1, 2020 Print numbers in boxes. Month Day 11810025 §,r!:¤ 4. American Indian or Alaska Native – Print name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. C Year of birth years 2 8. 12. Yes, born in American Samoa ➜ SKIP to question 11a What is the highest degree or level of school you have COMPLETED? Mark K J ONE box. If currently enrolled, mark I the previous grade or highest degree received. Yes, born in another U.S. state or U.S. territory NO SCHOOLING COMPLETED Are you a citizen or national of the United States? Yes, born abroad of U.S. citizen or U.S. national parent or parents No schooling completed Yes, U.S. citizen by naturalization – Print year of naturalization. C NURSERY OR PRESCHOOL THROUGH GRADE 12 Nursery school, preschool, or pre-kindergarten Kindergarten No, not a U.S. citizen or U.S. national (permanent resident) Grade 1 through 11 – Specify grade 1 – 11 C No, not a U.S. citizen or U.S. national (temporary resident) 9. Where were you born? Print name of U.S. state, U.S. territory, or foreign country. 12th grade – NO DIPLOMA HIGH SCHOOL GRADUATE Regular high school diploma GED or alternative credential When did you come to live in American Samoa? If you came to live in American Samoa more than once, print latest year. COLLEGE OR SOME COLLEGE Some college credit, but less than 1 year of college credit Year T 10. 1 or more years of college credit, no degree Associate’s degree (for example: AA, AS) a. At any time since February 1, 2020, have you attended school or college? Include only nursery or preschool, pre-kindergarten, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree. Bachelor’s degree (for example: BA, BS) R AF 11. Yes AFTER BACHELOR’S DEGREE Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) Doctorate degree (for example: PhD, EdD) No ➜ SKIP to question 12 b. Was that a public school or college, a private school or college, or home school? A Answer question 13 if you have a bachelor’s degree or higher. Otherwise, SKIP to question 14. Public school or public college D Private school or private college or home school 13. This question focuses on your BACHELOR’S DEGREE. What was the specific major or majors of any BACHELOR’S DEGREES you have received? (For example: chemical engineering, elementary teacher education, organizational psychology) 14. Have you completed requirements for a vocational training program at a trade school, hospital, or some other kind of school for occupational training or place of work? Do not include academic college courses. c. What grade or level were you attending? Mark K J ONE box. I Nursery school, preschool, or pre-kindergarten Kindergarten C 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) Yes No 3 §,r!B¤ 11810033 Grade 1 through 12 – Specify grade 1 – 12 15. 20. What is your ancestry or ethnic origin? Yes (For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.) 16. In 2019, did you receive benefits from the Food Stamp Program, SNAP (the Supplemental Nutrition Assistance Program), or NAP (Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks. No 21. a. Where was your mother born? Are you CURRENTLY covered by any of the following types of health insurance or health coverage plans? Mark "Yes" or "No" for EACH type of coverage in items a – h. Yes American Samoa No a. Insurance through a current or former employer or union (of yours or another family member) Outside American Samoa – Print name of U.S. state, U.S. territory, or foreign country below. C b. Insurance purchased directly from an insurance company (by you or another family member) c. Medicare, for people 65 and older, or people with certain disabilities b. Where was your father born? American Samoa d. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability Outside American Samoa – Print name of U.S. state, U.S. territory, or foreign country below. C T e. TRICARE or other military health care f. VA (enrolled for VA health care) a. Do you speak a language other than English at home? g. Indian Health Service Yes R AF 17. h. Any other type of health insurance or health coverage plan – Specify C No ➜ SKIP to question 18 b. What is this language? 22. For example: Korean, Italian, Spanish, Vietnamese. Yes c. How well do you speak English? Well Not well Not at all 18. No b. Are you blind or do you have serious difficulty seeing even when wearing glasses? D Very well a. Are you deaf or do you have serious difficulty hearing? Yes No Did you live at this address 5 years ago (on April 1, 2015)? Person is under 5 years old ➜ SKIP to question 20 No, different address in American Samoa No, outside American Samoa – Print name of U.S. state, U.S. territory, or foreign country below. C 19. 11810041 §,r!J¤ Yes, this address ➜ SKIP to question 20 What was your main reason for moving? Mark K J ONE box. I Employment To attend school Military Family-related Housing Natural disaster Other reason 4 B Answer questions 23a – c if you are 5 years old or over. Otherwise, the questionnaire is complete. 23. D Answer question 29 if you are female and 15 years old or over. Otherwise, SKIP to question 30a. 29. a. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? None or Yes No 30. b. Do you have serious difficulty walking or climbing stairs? b. Are you currently responsible for most of the basic needs of any grandchildren under the age of 18 who live in this place? c. Do you have difficulty dressing or bathing? Yes Yes No No ➜ SKIP to question 31 T c. How long have you been responsible for these grandchildren? If you are financially responsible for more than one grandchild, answer the question for the grandchild for whom you have been responsible for the longest period of time. R AF Answer question 24 if you are 15 years old or over. Otherwise, the questionnaire is complete. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? Less than 6 months 6 to 11 months 1 or 2 years Yes 3 or 4 years No 25. a. Do you have any of your own grandchildren under the age of 18 living in this place? No ➜ SKIP to question 31 No 24. Number of children Yes Yes C How many babies have you ever had, not counting stillbirths? Do not count stepchildren or children you have adopted. 5 or more years What is your marital status? Now married Widowed D Divorced Separated Never married ➜ SKIP to D 26. In the PAST 12 MONTHS did you get – Yes No §,r![¤ a. Married? 11810058 b. Widowed? c. Divorced? 27. How many times have you been married? Once Two times Three or more times 28. In what year did you last get married? Year 5 31. 35. Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard? Mark K J ONE box. I At what location did you work LAST WEEK? American Samoa – Print name of village below. C Never served in the military ➜ SKIP to question 34a Only on active duty for training in the Reserves or National Guard ➜ SKIP to question 33a Outside American Samoa – Print name of U.S. state, U.S. territory, or foreign country below. C Now on active duty On active duty in the past, but not now 36. When did you serve on active duty in the U.S. Armed Forces? Mark K J a box for EACH period in which you served, even if just I for part of the period. How did you usually get to work LAST WEEK? Mark K J ONE box for the method of transportation used for I most of the distance. September 2001 or later Car, truck, or private van/bus August 1990 to August 2001 (including Persian Gulf War) Public van/bus May 1975 to July 1990 Taxicab Vietnam Era (August 1964 to April 1975) Motorcycle February 1955 to July 1964 Bicycle Korean War (July 1950 to January 1955) Walked January 1947 to June 1950 Plane or seaplane World War II (December 1941 to December 1946) Boat, ferry, or water taxi T 32. Worked from home ➜ SKIP to question 44a November 1941 or earlier Other method a. Do you have a VA service-connected disability rating? R AF 33. Yes (such as 0%, 10%, 20%, ..., 100%) E No ➜ SKIP to question 34a Answer question 37 if you marked "Car, truck, or private van/bus" in question 36. Otherwise, SKIP to question 38. b. What is your service-connected disability rating? 37. 0 percent 10 or 20 percent 30 or 40 percent 50 or 60 percent 34. Person(s) 38. D 70 percent or higher How many people, including you, usually rode to work in the car, truck, or private van/bus LAST WEEK? LAST WEEK, what time did your trip to work usually begin? Hour a. LAST WEEK, did you work for pay at a job (or business)? Minute : a.m. p.m. Yes ➜ SKIP to question 35 39. b. LAST WEEK, did you do ANY work for pay, even for as little as one hour? How many minutes did it usually take you to get from home to work LAST WEEK? Minutes Yes No ➜ SKIP to question 40a 11810066 §,r!c¤ No – Did not work (or retired) 6 F 45. Answer questions 40 – 43a if you did NOT work last week. Otherwise, SKIP to question 43b. 40. During 2019, in the WEEKS WORKED, how many hours did you usually work each WEEK? Usual hours worked each WEEK a. LAST WEEK, were you on layoff from a job? Yes ➜ SKIP to question 40c G No Answer questions 46a – f if you worked in the past 5 years (since 2015). Otherwise, SKIP to question 47. b. LAST WEEK, were you TEMPORARILY absent from a job or business? 46. Yes, on vacation, temporary illness, maternity leave, other family/personal reasons, bad weather, etc. ➜ SKIP to question 43a DESCRIPTION OF EMPLOYMENT The next series of questions is about the type of employment you had last week. No ➜ SKIP to question 41 If you had more than one job, describe the one at which the most hours were worked. If you did not work last week, describe the most recent employment in the past five years (since 2015). c. Have you been informed that you will be recalled to work within the next 6 months OR been given a date to return to work? a. Which one of the following best describes your employment last week or the most recent employment in the past 5 years (since 2015)? Mark K J ONE box. I Yes ➜ SKIP to question 42 No During the LAST 4 WEEKS, have you been ACTIVELY looking for work? T PRIVATE SECTOR EMPLOYEE 41. For-profit company or organization Non-profit organization (including tax-exempt and charitable organizations) R AF Yes No ➜ SKIP to question 43a 42. GOVERNMENT EMPLOYEE Local or territorial government (for example: public elementary school) LAST WEEK, could you have started a job if offered one, or returned to work if recalled? Active duty U.S. Armed Forces or Commissioned Corps Federal government civilian employee Yes, could have gone to work SELF-EMPLOYED OR OTHER No, because of own temporary illness Owner of non-incorporated business, professional practice, or farm No, because of all other reasons (in school, etc.) 43. Owner of incorporated business, professional practice, or farm a. When did you last work, even for a few days? 2020 Worked without pay in a for-profit family business or farm for 15 hours or more per week D 2019 ➜ SKIP to question 44a 2015 to 2018 ➜ SKIP to G b. What was the name of your employer, business, agency, or branch of the Armed Forces? 2014 or earlier, or never worked ➜ SKIP to question 47 Yes 11810074 No ➜ SKIP to G 44. c. What kind of business or industry was this? Include the main activity, product, or service provided at the location where employed. (For example: elementary school, residential construction) a. During 2019 (all 52 weeks), did you work EVERY week? Count paid vacation, paid sick leave, and military service as work. Yes ➜ SKIP to question 45 No d. Was this mainly – Mark I J K ONE box. b. During 2019 (all 52 weeks), how many WEEKS did you work? Include paid time off and include weeks when you only worked for a few hours. manufacturing? wholesale trade? Weeks retail trade? other (agriculture, construction, service, government, etc.)? 7 §,r!k¤ b. LAST YEAR, 2019, did you work at a job or business at any time? e. What was your main occupation? (For example: 4th grade teacher, entry-level plumber) d. Did you receive any Social Security or Railroad Retirement income in 2019? Yes ➜ What was the amount? TOTAL AMOUNT – Dollars $ .00 No f. Describe your most important activities or duties. (For example: instruct and evaluate students and create lesson plans, assemble and install pipe sections and review building plans for work details) e. Did you receive any Supplemental Security Income (SSI) in 2019? Yes ➜ What was the amount? TOTAL AMOUNT – Dollars $ .00 No f. Did you receive any public assistance or welfare payments from the state or local welfare office in 2019? INCOME IN 2019 TOTAL AMOUNT – Dollars Mark K J the "Yes" box for each type of income you received, and I give your best estimate of the TOTAL AMOUNT during 2019. $ .00 R AF No Mark K J the "No" box to show types of income NOT received. I If your net income was a loss, mark the "Loss" box to the right of the dollar amount. g. Did you receive any retirement income, pensions, survivor or disability income in 2019? Include income from a previous employer or union, or any regular withdrawals or distributions from IRA, Roth IRA, 401(k), 403(b) or other accounts specifically designed for retirement. Do not include Social Security. For income received jointly, report only your share of the amount received or earned. a. Did you receive any wages, salary, commissions, bonuses, or tips in 2019? Yes ➜ What was the amount? TOTAL AMOUNT – Dollars Yes ➜ What was the amount from all jobs before deductions for taxes, bonds, dues, or other items? $ $ No D TOTAL AMOUNT – Dollars No .00 h. Did you have any other sources of income received regularly such as Department of Veterans Affairs (VA) payments, unemployment compensation, child support, or alimony in 2019? Do NOT include lump sum payments such as money from an inheritance or sale of a home. §,r!s¤ b. Did you have any self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships, in 2019? Yes ➜ What was the amount? Yes ➜ What was the net income after business expenses? TOTAL AMOUNT – Dollars TOTAL AMOUNT – Dollars $ $ .00 Loss No 48. What was your total income for 2019? Add entries in questions 47a to 47h; subtract any losses. If net income was a loss, enter the amount and mark K J the “Loss” box next to the dollar amount. I TOTAL AMOUNT for 2019 Yes ➜ What was the amount? TOTAL AMOUNT – Dollars No .00 No c. Did you receive any interest, dividends, net rental income, royalty income, or income from estates and trusts in 2019? Report even small amounts credited to an account. $ .00 11810082 47. T Yes ➜ What was the amount? OR None .00 Loss 8 $ .00 Loss