FormD-31 from the US Department of Commerce, Bureau of Census states:

"YOUR ANSWERS ARE CONFIDENTIAL. The Bureau of the Census is conducting the U.S. Census 2000. To ensure accuracy of this census it is important that everyone be counted. Census Day is April 1, 2000. We appreciate your participation and the cooperation of others in your community.

Your privacy is protected by law (Title 13 of the United States Code). No one other than Census Bureau staff can see your form or find out what you tell us -- no other government agency, no court of law, NO ONE.

Thank-you for helping ensure that the Census 2000 will be the best in our history."

Commonly known as "the long form" -- FormD-158 from the US Department of Commerce, Bureau of Census asks the following questions:

1. What is your name?

2. Male/Female

3. What is your date of birth? MM DD YYYY

4. Are you Spanish/Hispanic/Latino? For example, Mexican, Puerto Rican, Cuban or another Hispanic group?

__ No, not Spanish/Hispanic/Latino

__ Yes, Mexican, Mexican AM., Chicano

__ Yes, Puerto Rican

__ Yes, Cuban

__ Yes, other Spanish/Hispanic/Latin (What is this group?) 


5. Which of these categories best indicates your race, you may choose one or more races.

__ White

__ Black, African Am., or Negro

__ American Indian or Alaska Native (What is the name of your enrolled or principle tribe?)


__ Asian Indian

__ Chinese

__ Filipino

__ Japanese

__ Korean

__ Vietnamese

__ Other Asian (What is this race?)


__ Native Hawaiian

__ Guamanian or Chamorro

__ Samoan

__ Other Pacific Islander (What is this race?)


__ Some other race (What is this race?)


6. Do you stay overnight MOST OF THE TIME at an apartment or house, at a shelter, on the street, or at some other type of place?

__ An apartment or house

__ A shelter (What is the name of the shelter?)


__ On the street

__ Other place

7. What is the address of the place where you live or stay MOST OF THE TIME?

______House Number

________________________Street or road name

______Apartment Number



________________________State or foreign county

___________zip code

8. Including today, how many days during the past 7 days did you receive a meal from a SOUP KITCHEN or MOBILE FOOD VAN?

__ 7 days

__ 6 days

__ 5 days

__ 4 days

__ 3 days

__ 2 days

__ 1 day

__ None

9. Including last night, during the past 7 nights did you stay in a shelter?


10. What is your marital status?

__ Now married

__ Divorced

__ Never married

__ Widowed

__ Separated

11a. At any time since February 1, 2000, have you attended regular school or college? Include only nursery school or preschool, kindergarten, elementary school, and schooling which leads to a high school diploma or a college degree.

__ No, has not attended since February 1

__ Yes, public school, public college

__ Yes, private school, private college

11b. What grade or level are you attending?

__ Nursery School, preschool

__ Kindergarten

__ Grade 1 to grade 4

__ Grade 5 to grade 8

__ Grade 9 to grade 12

__ College, undergraduate years (freshman to senior)

__ Graduate or professional school (for example medical, dental or law school)

12. What is the highest degree or level of school you have COMPLETED?

__ No schooling completed

__ Nursery school to 4th grade

__ 5th grade or 6th grade

__ 7th grade or 8th grade

__ 9th grade

__ 10th grade

__ 11th grade

__ 12th grade (no diploma)

__ HIGH SCHOOL GRADUATE - high school diploma

__ some college credit, but less than 1 year

__ Associate degree (for example, AA, AS)

__ Bachelor's degree (for example BA, AB, BS)

__ Master's degree (for example MA, MS, MEng, MEd, MSW, MBA)

__ Professional degree (for example MD, DDS, DVM, LLB, JD)

__ Doctorate degree (for example PhD, EdD)

13. What is your ancestry or ethnic origin?

14a. Do you speak a language other than English at home?

__ Yes

__ No

14b. What is that language?

14c. How well do you speak English?

__ Very well

__ Well

__ Not well

__ Not at all

15. Where were you born?

__ In the United States - Print name of state.

__ Outside the United States - Print name of foreign county, or Puerto Rico, Guam, etc.

16. Are you a CITIZEN of the United States?

__ Yes, born in the United States (skip to 18a)

__ Yes, born in Puerto Rico, Guam, the US Virgin Islands, or Northern Marianas

__ Yes, born abroad of American parent or parents

__ Yes, a US citizen by naturalization

__ No, not a citizen of the US

17. What year did you come to live in the United States?

18a. (If the response to question 6 is "on the street" skip to 18b.

Did you live in your current house, apartment, dormitory, shelter or institution 5 years ago on April 1, 1995?

__ Person is under 5 years old (end interview)

__ Yes, this house (skip to 19)

__ No, outside the United States -- Print name of foreign country, or Puerto Rico, Guam, etc. below then skip to 19.


__ No, different house in the United States

18b. Where did you live five years ago? If previous residence is outside the US, enter county. Name of city, town or post office?


Did you live inside the limits of that city or town?

__ Yes

__ No

Name of county?

Name of state?

What was the Zip Code?

19. Do you have any of the following long-lasting conditions?

a. Blindness, deafness, or a severe vision or hearing impairment? Y/N

b. A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting or carrying?


20. Because of physical, mental or emotional condition lasting 6 months or more, do you have any difficulty doing any of the following activities:

a. Learning, remembering or concentrating Y/N

b. Dressing, bathing, or getting around inside the home? Y/N

c. Ask if the person is 16 years old or over. Going outside the home alone to shop or visit a doctor's office? Y/N

d. Ask if this person is 16 years old or over. Working at a job or business Y/N

21.Interviewer instruction - Refer to question 3 on page 1 to mark a response box below:

__ born on or before April 1, 1985 or at least age 15 by April 1, 2000 - ask 22a

__ born after April 1, 2000 - END INTERVIEW

IF question 3 is blank, ASK - Were you under 15 years of age on April 1, 2000?


__ No, ASK 22a

22a. Do you have any of your own grandchildren under the age of 18 living with you?

__ Yes

__ No - Skip to 23a.

22b. Are you currently responsible for most of the basic needs of any grandchild(ren) under the age of 18 who live(s) with you?

__ Yes

__ No - Skip to 23a.

22c. How long have you been responsible for the(se) grandchild(ren) If more than one grandchild lives with you, answer the question for the grandchild for whom you have been financially responsible for the longest period of time.

__ less than 6 months

__ 6 to 11 months

__ 1 to 2 years

__ 3 to 4 years

__ 5 years or more

23a. Have you ever served on active duty in the US 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

__ Yes, on active duty in the past but not now

__ No, training for Reserves or National Guard only - skip to 24

__ No, never served in the military - skip to 24

23b. When did you serve on active duty in the US Armed Forces?

__ April 1995 or later

__ August 1990 to March 1995 (including thee Persian Gulf War)

__ September 1980 to July 1990

__ May 1975 to August 1980

__ Viet Nam Era (Aug 1964-April 1975)

__ February 1955 to July 1964

__ Korean conflict (June 1950-January 1955)

__ World War II (September 1940-July 1947)

__ Some other time

23c. In total, how many years of active-duty military service have you had

__ Less than 2 years

__ 2 years or more

24. LAST WEEK, did you do ANY work for either pay or profit? Answer "Yes" even if you worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or were on active duty in the Armed Service

__ Yes

__ No, skip to 28a

25. At What location did you work LAST WEEK? If the person worked more than one location, print where (he/she) worked most last week.

a. Address (number and street name)?

b. Name of city, town or post office?

c. Is the work location inside the limits of that city or town? Y/N

d. What county?

e. Name of US State or foreign county?

f. What was the ZIP Code?

26a. How did you usually get to work LAST WEEK? If the person usually used more than one method of transportation during the trip mark the one used for most of the distance.

__ car, truck, can - continue with 26b

__ bus or trolley bus - skip to 27a

__ Streetcar or trolley car - - skip to 27a

__ Subway or elevated - skip to 27a

__ Railroad - skip to 27a

__ Ferryboat - skip to 27a

__ Taxicab - skip to 27a

__ Motorcycle - skip to 27a

__ Bicycle - skip to 27a

__ Walked - skip to 27a

__ Worked at home - skip to 30

__ Other method - skip to 27a

b. How many people, including yourself, usually rode to work in the car, truck, or van LAST WEEK?

__ Drove alone

__ 2 people

__ 3 people

__ 4 people

__ 5 or 6 people

__ 7 or more people

27a. What time did you usually leave home to go to work LAST WEEK?

__:__ am/pm

27b. How many minutes did it usually take you to get from home to work LAST

WEEK? _____ minutes - Skip to 30.

28a. LAST WEEK, were you on layoff from a job?

__ Yes - skip to 28c

__ No

28b. LAST WEEK, were you TEMPORARILY absent or on vacation from a job or business?

__ Yes, on vacation, temporary illness, labor dispute, etc. - Skip to 29.

__ No - Skip to 28d

28c. 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?

__ Yes - Skip to 28e

__ No

28d. Have you been looking for work during the last 4 weeks?

__ Yes

__ No - Skip to 29

28e. LAST WEEK, could you have started a job if offered one, or returned to work if recalled? If "No" Ask - For what reason?

__ Yes, could have gone to work

__ No, because of temporary illness

__ No, because of all other reasons (in school, etc.)

29. When did you last work, even for a few days?

__ 1995-2000

__ 1994 or earlier, or never worked - Skip to 34.

30. The next set of questions is about your current or most recent job activity. Clearly describe your chief job activity or business last week. If you had more than one job, describe the one at which the most hours were worked. If you had no job or business last week, give the information for the last job or business worked since 1995.

30a. For whom did you work? If now on active duty in the Armed forces mark X in this box [] and print the branch of the Armed Forces.

Name of Company, Business or other employer


30b. What kind of business or industry was this? Describe the activity at location where employed. (For example: hospital, newspaper publishing, mail order house, auto repair shop, bank.)


30c. Is this business or industry mainly - Mark ONE box

__ Manufacturing?

__ Wholesale trade?

__ Retail trade?

__ Some other business or industry; such as agriculture, construction, service, government, etc.?

31a. What kind of work are you doing? (For example: registered nurse, personnel manager, supervisor of order department, auto mechanic, accountant.)


31b. What were your most important activities or duties? (For example: patient care, directing hiring policies, supervising order clerks, repairing automobiles, reconciling financial records.)


32. Were you - Mark ONE box.

__ An employee of a PRIVATE-FOR-PROFIT company or business or of an individual, for wages, salary, or commissions?

__ An employee of PRIVATE-NOT-FOR-PROFIT tax-exempt, or charitable organization?

__ A local GOVERNMENT employee (city, county, 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?

33a. LAST YEAR, 1999, did you work at a job or business at any time?

__ Yes

__ No - Skip to 34

33b. How many weeks did you work in 1999? Count paid vacation, paid sick leave and military service. ____ weeks.

33c. During the weeks WORKED in 1999, how many hours did you usually work each WEEK? Usual hours worked each WEEK ____

34. The next set of questions is about each income source during 1999. If exact amount is not known, please give best estimate. If the net income was a loss, please give the dollar amount of the loss (and mark the "Loss" box next to the dollar amount).

34a. Did you receive any wages, salary, commissions, bonuses, or tips in 1999?

__ Yes - What was the amount from all jobs before deductions for taxes, bonds, dues or other items? Annual Amount - Dollars

$_____,________.00 [loss]


34b. Did you have any self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships in 1999.

__ Yes - What was the net income after business expenses/

Annual amount - Dollars

$_____,________.00 [loss]

__ No

34c. Did you receive any interest, dividends, net rental income, royalty income, or income from estates and trusts in 1999?  Report even small amounts credited to an account.

__ Yes - What was the dollar amount?

Annual amount - Dollars

$_____,________.00 [loss]

__ No

34d. Did you receive any Social Security or Railroad Retirement income in 1999?

__ Yes - What was the dollar amount?

Annual amount - Dollars


__ No

34e. Did you receive any Supplemental Security Income (SSI) in 1999?

__ Yes - What was the dollar amount?

Annual amount - Dollars


__ No

34f. Did you receive any public assistance or welfare payments from the state or local welfare office in 1999?

__ Yes - What was the dollar amount?

Annual amount - Dollars


__ No

34g. Did you receive retirement, survivor, or disability pensions in 1999?

Do NOT include Social Security.

__ Yes - What was the dollar amount?

Annual amount - Dollars


__ No

34h. Did you have any other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony in 1999? Do not include lump-sum payments such as money from an inheritance or sale of a home?

__ Yes - What was the dollar amount?

Annual amount - Dollars


__ No

35. D not ask this question if 34a-34h are completed. Instead sum these entries and subtract any losses. If that total amount was a loss, mark the "loss" box next to the amount.

What was your total income in 1999?

__ Yes - What was the dollar amount?

Annual amount - Dollars

[none] $_____,________.00 [loss]

36. The Census Bureau has been counting people in this area. Did you fill out another census form during the past week?

__ No

__ Yes

__ Don't Know

Thank-you for completing this official US Census 2000 form. The Census Bureau estimates that, on average, each respondent will take 24 minutes to complete this form including the time for reviewing the instructions and answers. Comments about the estimate should be directed to the Associate Director for Finance and Administration, Attn.: Paperwork Reduction Project 0607-0856, Room 3104, Federal Building 3, Bureau of the Census, Washington, DC 20233.

Respondents are not require to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget.

CERTIFICATION: I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.

Enumerator's signature & date


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