The Puerto Rico Community Survey 2010
U.S. Department of Commerce
Economics and Statistics Administration
U.S. Census Bureau
Please complete this form and return it as soon as possible after receiving it in the mail.
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.
If you need help or have questions about completing this form, please call 1-800-354-7271. The telephone call is free.
Necesita ayuda? Si usted habla espanol y necesita ayuda para completar su cuestionario, llame sin cargo alguno al 1-800-354-7271. Usted tambien puede pedir un cuestionario en espanol o completar su entrevista por telefono con un entrevistador que habla espanol.
For more information about the American Community Survey, visit our web site at: http://www.census.gov/acs/www/.
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.
First name ____
Area code + Number _ _ _ _ _ _ _ _ _ _
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.
[Questions 1-6 were asked of all persons.]
1. What is [this person's] name?
First name ____
2. How is this person related to Person 1?
 Person 1
Person 1 is the person living or staying here in whose name this house or apartment is owned, bought, or being rented. If there is no such person, start with the name of any adult living or staying here.
[For persons 2 - 5]
Relationship of Person [2 - 5] to Person 1.
 Husband or wife
 Son-in-law or daughter-in-law
 Biological son or daughter
 Other relative
 Adopted son or daughter
 Roomer or boarder
 Stepson or stepdaughter
 Housemate or roommate
 Brother or sister
 Unmarried partner
 Father or mother
 Foster child
 Other nonrelative
3. What is [the respondent?s] sex?
4. What is [the respondent?s] age and what is [this person's] date of birth?
Age (in years) _ _ _
Month of Birth _ _
Day of Birth_ _
Year of Birth _ _ _ _
Note: Please answer both question 5 about Hispanic origin and question 6 about race. For this survey, Hispanic origins are not races.
5. Is [the respondent] of Hispanic, Latino, or Spanish origin?
 Yes, Mexican, Mexican Am., Chicano
 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) ____
6. What is [the respondent's] race?
 Black, African Am., or Negro
 American Indian or Alaska Native-- (Print name of enrolled or principal tribe.) ____
 Asian Indian
 Native Hawaiian
 Guamanian or Chamorro
 Other Asian -- (Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.) ____
 Other Pacific Islander -- (Print race, for example, Fijian, Tongan, and so on.) ____
 Some other race -- (Print race) ____
Note: 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.
Last Name ____
First Name ____
Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.
[Questions 1-3 were asked of all households.]
1. Which best describes this building?
 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 20-49 apartments
 A building with 50 or more apartments
 Boat, RV, van, etc.
2. About when was this building first built?
 1980 to 1989
 1970 to 1979
 1960 to 1969
 1950 to 1959
 1940 to 1949
 1939 or earlier
3. When did person 1(listed on page 2) move into this house, apartment, or mobile home?
A - Answer questions 4-6 only if this is a house or a mobile home; otherwise, skip to question 7a.
[Questions 4-6 were asked of households living in independent houses and mobile homes.]
4. How many acres is this house or mobile home on?
 1 to 9.9 acres
 10 or more acres
5. In the past 12 months, what were the actual sales of all agricultural products from this property?
 $1 to $999
 $1,000 to $2,499
 $2,500 to $4,999
 $5,000 to $9,999
 $10,000 or more
6. Is there a business (such as a store or barber shop) or a medical office on this property?
[Questions 7 - 14 were asked of all households.]
7. a) How many separate rooms are in this house, apartment, or mobile home?
Include bedrooms, kitchens, etc.
Exclude bathrooms, porches, balconies, foyers, halls, or unfinished basements.
Number of rooms ____
7. b) How many of these rooms are bedrooms?
Number of bedrooms ____
8. Does this house, apartment, or mobile home have:
a) Hot and cold running water?
9. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?
 6 or more
10. Which fuel is used most for heating this house, apartment or mobile home?
 Gas: bottled, tank or LP
 Fuel oil, kerosene, etc.
 Coal or coke
 Solar energy
 Other fuel
 No fuel used
11. a) Last month, what was the cost of electricity for this house, apartment, or mobile home?
 Included in rent or condominium fee
 No charge or electricity not used
11. b) Last month, what was the cost of gas for this house, apartment or mobile home?
 Included in rent or condominium fee
 Included in electricity payment entered above
 No charge or gas not used
11. c) In the past 12 months, what was the cost of water and sewer for this house, apartment, or mobile home?
Past 12 months' cost in dollars $____.00
 Included in rent or condominium fee
 No charge
11. d) In the past 12 months, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?
Past 12 month's cost in dollars: $_ _ _ _.00
 Included in rent or condominium fee
 No charge or these fuels not used.
12. In the past 12 months, did anyone in this household receive Food Stamps or a Food Stamp benefit card?
13. Is this house, apartment, or mobile home part of a condominium?
Monthly Amount in dollars $____.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.
 Owned by you or someone in this household free and clear (without a mortgage or loan)?
 Occupied without payment of rent? Skip to [C]
B - Answer questions 15a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 16.
[Question 15 was asked of households living in rented houses, apartments or mobile homes.]
15. a) What is the monthly rent for this house, apartment, or mobile home?
15. b) Does this monthly rent include any meals?
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.
[Questions 16-20 were asked of households if a household member owns the dwelling or is buying one.]
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?
17. What are the annual real estate taxes on this property?
18. What is the annual payment for fire, hazard, and flood insurance on this property?
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, contract to purchase
 No - skip to question 23a
19. b) How much is the regular monthly mortgage payment on this property?
Monthly amount in dollars $_ _ _ _ _.00
 No regular payment required - Skip to question 23a
19. c) Does the regular monthly mortgage payment include payments for real estate taxes on this property?
 No, taxes paid separately or taxes not required
19. d) Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on this property?
 No, insurance paid separately or no insurance
20. a) Do you or any member of this household have a second mortgage or a home equity loan on this property?
 Yes, second mortgage
 Yes, second mortgage and home equity loan
 No - Skip to D
20. b) How much is the regular monthly payment on all second or junior mortgages and all home equity loans on this property?
 No regular payment required
D - Answer question 21 if this is a mobile home. Otherwise, skip to E.
[Question 21 was asked of households living in mobile homes.]
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?
Annual costs in dollars $____.00
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.
[Questions 7-48 were asked of all persons.]
Please copy the name of [the person] from Page 2, then continue answering questions below.
First Name ____
7. Where was this person born?
 Outside the United States - (Print name of foreign country, or Puerto Rico, Guam, etc.) ____
8. Is this person a citizen of the United States?
 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
9. When did this person come to live in Puerto Rico?
10. a) At any time in the last 3 months, has this person attended school or college?
 No, has not attended in the last 3 months - Skip to question 11
 Yes, public school, public college
 Yes, private school, private college, home school
10. b) What grade or level was this person attending?
 Nursery school, preschool
 Grade 1 through 12(Specify grade 1-12) _ _
 College undergraduate years (freshman to senior)
 Graduate or professional school beyond a bachelor's degree
11. What is the highest degree or level of school this person has completed?
No schooling completed
 Grade 1 through 11 (Specify grade 1-11) _ _
 12th grade with no diploma
 GED or alternative credential
 1 or more years of college credit, no degree
 Associate's degree (for example: AA, AS)
 Bachelor's degree (for example: BA, BS)
 Professional degree beyond a bachelor's degree (for example: MD, DDS, DVM, LLB, JD)
 Doctorate degree (for example: PhD, EdD)
F - Answer question 12 if this person has a bachelor's degree or higher. Otherwise, skip to question 13.
[Question 12 was asked of persons with a bachelor?s degree of higher.]
12. This question focuses on this person's Bachelor's degrees.
[Question 13- 17 were asked of all persons.]
13. What is this person's ancestry or ethnic origin?
14. a) Does this person speak a language other than English at home?
 No - Skip to question 15a
14. c) How well does this person speak English?
 Not well
 Not at all
15. a) Did this person live in this house or apartment 1 year ago?
 Yes, this house - Skip to question 16
 No, outside the United States and Puerto Rico
15. b) Where did this person live 1 year ago?
Name of city, town, or post office ____
Name or U.S. county or municipio in Puerto Rico ____
Name of U.S. state or Puerto Rico ____
Zip Code _ _ _ _ _
16. Is this person currently covered by any of the following types of health insurance or health coverage plans?
17. a) Is this person deaf or does he/she have serious difficulty hearing?
17. b) Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?
G - Answer question 18a-c if this person is 5 years old or over. Otherwise, skip to the questions for Person 2 on page 12.
[Question 18 was asked of persons age 5 and above.]
18. a) Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?
18. b) Does this person have serious difficulty walking or climbing stairs?
c) Does this person have difficulty dressing or bathing?
H - Answer question 19 if this person is 15 years old or over. Otherwise, skip to the questions for Person 2 on page 12.
[Question 19 was asked of persons age 15 and above.]
19. Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor's office or shopping?
20. What is this person's marital status?
 Never married -- Skip to I
21. In the past 12 months did this person get:
22. How many times has this person been married?
 Two times
 Three or more times
23. In what year did this person last get married?
I - Answer question 24 if this person is female and 15-50 years old. Otherwise, skip to question 25a.
[Question 24 was asked of females aged 15-50.]
24. Has this person given birth to any children in the past 12 months?
[Question 25 ? 31 were asked of all persons.]
25. a) Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?
 No -- Skip to question 26
25. 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?
 No -- Skip to question 26
25. c) How long has this grandparent been responsible for the(se) grandchild(ren)?
 Less than 6 months
 6 to 11 months
 1 or 2 years
 3 or 4 years
 5 or more years
26. Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?
 Yes, now on active duty
 Yes, on active duty during the last 12 months, but not now
 Yes, on active duty in 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
27. When did this person serve on active duty in the U.S. Armed Forces?
 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 (June 1950 to January 1955)
 January 1947 to June 1950
 World War II (December 1941 to December 1946)
 November 1941 or earlier
28. a) Does this person have a VA service-connected disability rating?
 No -- Skip to question 29a
28. b) What is this person's service-connected disability rating?
 10 or 20 percent
 30 or 40 percent
 50 or 60 percent
 70 percent or higher
29. a) Last week, did this person work for pay at a job (or business)?
 No -- Did not work (or retired)
29. b) Last week, did this person do any work for pay, even for as little as one hour?
 No -- Skip to question 35a
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)
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection.
30. b) Name of city, town, or post office ____
30. c) Is the work location inside the limits of that city or town?
 No, outside the city/town limits
30. e) Name of U.S. state or foreign country ____
31. How did this person usually get to work last week?
 Car, truck, or van
 Bus or trolley bus
 Streetcar or trolley car
 Subway or elevated
 Worked at home -- Skip to question 38a
 Other method
J - Answer question 32 if you marked "car, truck or van" in question 31.
Otherwise, skip to question 33.
[Question 32 was asked of people who commute to work by car, truck or van.]
32. How many people, including this person, usually rode to work in the car, truck or van last week?
[Questions 33 ? 34 were asked of all persons.]
33. What time did this person usually leave home to go to work last week?
_ _ Minute
34. How many minutes did it usually take this person to get from home to work last week?
K - Answer questions 35-38 only if this person did not work last week.
Otherwise, skip to question 39a.
[Questions 35-38 were asked of people who did not work last week.]
35. a) Last week, was this person on layoff from a job?
35. b) Last week, was this person temporarily absent from a job or business?
 No -- Skip to question 36
35. 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?
36. During the last 4 weeks, has this person been actively looking for work?
 No -- Skip to question 38
37. Last week, could this person have started a job if offered one, or returned to work if recalled?
 No, because of own temporary illness
 No, because of all other reasons (in school, etc.)
38. When did this person last work, even for a few days?
 1 to 5 years ago -- Skip to L
 Over 5 years ago or never worked -- Skip to question 47
[Questions 39 ? 40 were asked of all persons.]
39. a) During the past 12 months(52 weeks), did this person work 50 or more weeks? Count paid time off as work.
39. b) How many weeks did this person work, even for a few hours, including paid vacation, paid sick leave, and military service?
 48 to 49 weeks
 40 to 47 weeks
 27 to 39 weeks
 14 to 26 weeks
 13 weeks or less
40. How many hours did this person usually work each week?
Usual hours worked each week: _ _ _
L - Answer questions 41-46 if this person worked in the past 5 years.
Otherwise, skip to question 47.
[Questions 41-46 were asked of people who worked in the past 5 years.]
41-46: Current or more 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.
 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, 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?
42. For whom did this person work?
 Print the branch of the Armed Forces
Name of company, business, or other employer: ____
43. What kind of business or industry was this?
 Wholesale trade?
 Retail trade?
 Other (agriculture, service, government, etc.)?
45. What kind of work was this person doing?
46. What were this person's most important activities or duties?
[Questions 47?48 were asked of all persons.]
47. Income in the past 12months.
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.)
Mark (X) the "no" box to show types of income not received
If net income was a loss, mark the "loss" box.
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.
48. What was this person's total income during the past 12 months?
 None or $_ _ _ _ _ _ _.00 (Total amount for the past 12 months)
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.