The Puerto Rico Community Survey 2019
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 1-800-717-7381. 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 espanol 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/.
Start Here
Please print today's date.
Day [ ][ ]
Year [ ][ ][ ][ ]
Please print the name and telephone number of the person who is filling out this form. We will only contact you if needed for official Census Bureau business.
___________________________________
First Name
___________________________________
MI
____
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.
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.
Person 1
(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.)
1. What is Person 1's name?
Last Name (Please print) ______________________
First Name _____________________
MI ___
2. How is this person related to Person 1?
3. What is Person 1's sex? Mark (X) ONE box.
[ ] Female
4. 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.
Month [ ][ ]
Day [ ][ ]
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 Person 1 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 Person 1's race? Mark (X) one or more boxes.
[ ] Black or African Am.
[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe. -- __________________
[ ] Asian Indian
[ ] Japanese
[ ] Native Hawaiian
[ ] Chinese
[ ] Korean
[ ] Guamanian or Chamorro
[ ] Filipino
[ ] Vietnamese
[ ] Samoan
[ ] 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. -- ___________________________
[Repeat for persons X = 2 - 5.]
Last Name (Please print)______________________
First Name _____________________
MI___
2. How is this person related to Person 1? ?
[ ] Opposite-sex unmarried partner
[ ] Same-sex husband/wife/spouse
[ ] Same-sex unmarried partner
[ ] 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
[ ] Roommate or housemate
[ ] Foster child
[ ] Other nonrelative
3. What is Person X's sex? Mark (X) ONE box.
[ ] Female
4. What is Person X's age and what is Person X'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 Question 6 about race. For this survey, Hispanic origins are not races.
5. Is Person X 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 Person X's race? Mark (X) one or more boxes.
[ ] Black or African Am.
[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe. -- __________________
[ ] Asian Indian
[ ] Japanese
[ ] Native Hawaiian
[ ] Chinese
[ ] Korean
[ ] Guamanian or Chamorro
[ ] Filipino
[ ] Vietnamese
[ ] Samoan
[ ] 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. --
____________________________________________________
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.
[Repeat for Persons Y = 6 - 12.]
Person Y
Last Name (Please print) ______________________
First Name _____________________
MI___
[ ] Female
Age (in years)[ ][ ][ ]
Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.
1. Which best describes this building? Include all apartments, flats, etc., even if vacant.
[ ] 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.
2. About when was this building first built?
[ ] 1990 to 1999
[ ] 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?
Year [ ][ ][ ][ ]
[A] - Answer questions 4-5 if this is a HOUSE OR A MOBILE HOME; otherwise, SKIP to question 6a.
4. How many cuerdas is this house or mobile home on?
[ ] 1 to 9.9 cuerdas
[ ] 10 or more cuerdas
5. IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?
[ ] $1-$999
[ ] $1,000 to $2,499
[ ] $2,500 to $4,999
[ ] $5,000 to $9,999
[ ] $10,000 or more
- INCLUDE bedrooms, kitchens, etc. EXCLUDE bathrooms, porches, balconies, foyers, halls, or unfinished basements.
[ ][ ]
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".
[ ][ ]
7. Does this house, apartment, or mobile home have --
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
8. Can you or any member of this household both make and receive phone calls when at this house, apartment, or mobile home? Include calls using cell phones, land lines, or other phone devices..
[ ] No
9. At this house, apartment, or mobile home- do you or any member of this household own or use any of the following types of computers?
a) Desktop or laptop
[ ] No
b) Smartphone
[ ] No
c) Tablet or other portable wireless computer
[ ] No
d) Some other type of computer
[ ] No
10. At this house, apartment, or mobile home - do you or any member of this household have access to the Internet?
[ ] Yes, without paying a cell phone company or Internet service provider - SKIP to question 12
[ ] No access to the Internet at this house, apartment, or mobile home - SKIP to question 12
11. Do you or any member of this household have access to the Internet using a -
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
12. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?
[ ] 1
[ ] 2
[ ] 3
[ ] 4
[ ] 5
[ ] 6 or more
13. Which FUEL is used MOST for heating this house, apartment or mobile home?
[ ] Gas: bottled, tank or LP
[ ] Electricity
[ ] Fuel oil, kerosene, etc.
[ ] Coal or coke
[ ] Wood
[ ] Solar energy
[ ] Other fuel
[ ] No fuel used
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge or electricity not used
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] Included in electricity payment entered above
[ ] No charge or gas not used
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge
$[ ],[ ][ ][ ].00
OR
[ ] Included in rent or condominium fee
[ ] No charge or these fuels not used
15. IN THE PAST 12 MONTHS, did you or any member of this household receive benefits from the Nutritional Assistance Program? Do NOT include WIC, the School Lunch Program, or assistance from food banks.
[ ] No
16. Is this house, apartment, or mobile home part of a condominium?
$[ ],[ ][ ][ ].00
OR
[ ] None
[ ] No
17. Is this house, apartment, or mobile home -- Mark (X) ONE box.
[ ] 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 on the next page
[B] - Answer questions 18a and b if this house, apartment, or mobile home is RENTED. Otherwise, SKIP to question 19.
18. a) What is the monthly rent for this house, apartment, or mobile home?
$[ ],[ ][ ][ ].00
b) Does the monthly rent include any meals?
[ ] No
[C] - Answer questions 19-23 if you or any member of this household OWNS or IS BUYING this house, apartment, or mobile home. Otherwise, SKIP to [E].
19. 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?
$[ ],[ ][ ][ ],[ ][ ][ ].00
20. What are the annual real estate taxes on THIS property?
$[ ][ ],[ ][ ][ ].00
OR
[ ] None
21. What is the annual payment for fire, hazard, and flood insurance on THIS property?
$[ ],[ ][ ][ ].00
OR
[ ] None
[ ] Yes, contract to purchase
[ ] No - SKIP to question 23a
$[ ][ ],[ ][ ][ ].00
OR
[ ] No regular payment required - SKIP to question 23a
[ ] No, taxes paid separately or taxes not required
[ ] No, insurance paid separately or no insurance
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]
$[ ][ ],[ ][ ][ ].00
OR
[ ] No regular payment required
[D] - Answer question 24 if this is a MOBILE HOME. Otherwise, SKIP to [E]
24. 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.
$[ ][ ],[ ][ ][ ].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.
Person 1
[This form repeats for each person listed]
Please copy the name of Person 1 from page 2, then continue answering questions below.
Last Name
_____________________________
First Name
_____________________________
MI
____
7. Where was this person born?
[ ] Outside the United States - Print Puerto Rico or name of foreign country, or U.S. Virgin Islands, Guam, etc.__________________________
8. Is this person a citizen of the United States?
[ ] 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 --
[ ][ ][ ][ ]
[ ] No, not a U.S. citizen
9. When did this person come to live in Puerto Rico? If this person came to live in Puerto Rico more than once, print latest year.
[ ] Yes, public school, public college
[ ] Yes, private school, private college, home school
[ ] Kindergarten
[ ] Grade 1 through 12 -- Specify grade 1-12 -- [ ][ ]
[ ] 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)
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.
[ ] Kindergarten
[ ] Grade 1 through 11 -- Specify grade 1-11 -- [ ][ ]
[ ] 12th grade -- 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.
12. This question focuses on this person's 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)
_______________________________
_______________________________
_______________________________
13. What is this person's ancestry or ethnic origin?
_______________________________
_______________________________
(For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)
[ ] No - SKIP to question 15a
______________________________For example: Korean, Italian, Spanish, Vietnamese
[ ] Well
[ ] Not well
[ ] Not at all
[ ] 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, different house in Puerto Rico or the United States
Development or condominium name
Number and street name
___________________________________
___________________________________
Name of city, town, or post office
___________________________________
Name of municipio in Puerto Rico or U.S. county
____________________________________
Enter Puerto Rico or name of U.S. state
____________________________
ZIP Code
[ ][ ][ ][ ][ ]
16. Is this person 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.
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[G] - Answer question 17a if this person is covered by health insurance. Otherwise, SKIP to question 18a.
[ ] No -- SKIP to 18a
[ ] No
18.
[ ] No
[ ] No
[H] - Answer question 19a-c if this person is 5 years old or over. Otherwise, SKIP to the questions for PERSON 2 on page 12.
[ ] No
[ ] No
[ ] No
[I] - Answer question 20 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.
20. 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?
[ ] No
21. What is this person's marital status?
[ ] Widowed
[ ] Divorced
[ ] Separated
[ ] Never married -- SKIP to J
22. In the PAST 12 MONTHS did this person get --
[ ] No
[ ] No
[ ] No
23. How many times has this person been married?
[ ] Two times
[ ] Three or more times
24. In what year did this person last get married?
[ ][ ][ ][ ]
[J] Answer question 25 if this person is female and 15-50 years old. Otherwise, SKIP to question 26a.
25. In the PAST 12 MONTHS, has this person given birth to any children?
[ ] No
[ ] No -- SKIP to question 27
[ ] No -- SKIP to question 27
[ ] 6 to 11 months
[ ] 1 or 2 years
[ ] 3 or 4 years
[ ] 5 or more years
27. Has this person ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard? Mark (X) ONE box.
[ ] Only on active duty for training in the Reserves or National Guard (SKIP to question 29a)
[ ] Now on active duty
[ ] On active duty in the past, but not now
28. 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.
[ ] August 1990 to August 2001 (including Persian Gulf War)
[ ] May 1975 to July 1990
[ ] Vietnam era (August 1964 to April 1975)
[ ] February 1955 to July 1964
[ ] Korean War (July 1950 to January 1955)
[ ] January 1947 to June 1950
[ ] World War II (December 1941 to December 1946)
[ ] November 1941 or earlier
[ ] No -- SKIP to question 30a
[ ] 10 or 20 percent
[ ] 30 or 40 percent
[ ] 50 or 60 percent
[ ] 70 percent or higher
[ ] No - Did not work (or retired)
[ ] No ( SKIP to question 36a
31. 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
Development or condominium name
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.
_________________________________
[ ] No, outside the city/town limits
_________________________________
_________________________________
[ ][ ][ ][ ][ ]
32. How did this person usually get to work LAST WEEK?
Mark (X) ONE box for the method of transportation used for most of the distance.
[ ] Bus
[ ] Subway or elevated rail
[ ] Long-distance train or commuter rail
[ ] Carro público
[ ] Ferryboat
[ ] Taxicab
[ ] Motorcycle
[ ] Bicycle
[ ] Walked
[ ] Worked at home - SKIP to question 40a
[ ] Other method
[K] - Answer question 33 if you marked "car, truck or van" in question 32. Otherwise, SKIP to question 34.
33. How many people, including this person, usually rode to work in the car, truck or van LAST WEEK?
[ ][ ]
34. LAST WEEK, what time did this person?s trip to work usually begin?
[ ][ ]:[ ][ ]
[ ]a.m.
[ ] p.m.
35. How many minutes did it usually take this person to get from home to work LAST WEEK?
[ ][ ][ ]
[L] - Answer questions 36-39 if this person did NOT work last week. Otherwise, SKIP to question 40a.
[ ] No
[ ] No --SKIP to question 37
[ ] No
37. During the LAST 4 WEEKS, has this person been ACTIVELY looking for work?
[ ] No -- SKIP to question 39
38. 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.)
39. When did this person last work, even for a few days?
[ ] 1 to 5 years ago - SKIP to [M]
[ ] Over 5 years ago or never worked -SKIP to question 43
[ ] No
[ ][ ]
41. During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did this person usually work each WEEK?
[ ][ ][ ]
[M] - Answer questions 42a-f if this person worked in the past 5 years. Otherwise, SKIP to question 43.
42. DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment this person had last week.
If this person had more than one job, describe the one at which the most hours were worked. If this person did not work last week, describe the most recent employment in the past five years.
a) Which one of the following best describes this person?s employment last week or the most recent employment in the past 5 years?Mark (X) ONE box
[ ] For-profit company or organization
[ ] Non-profit organization (including tax-exempt and charitable organizations)
GOVERNMENT EMPLOYEE
[ ] Local government (for example: city, county, or municipio)
[ ] State government (including school districts and state universities)
[ ] Active duty U.S. Armed Forces or Commissioned Corps
[ ] Federal government civilian employee
SELF-EMPLOYED OR OTHER
[ ] Owner of non-incorporated business, professional practice, or farm
[ ] Owner of incorporated business, professional practice, or farm
[ ] Worked without pay in a for-profit family business or farm for 15 hours or more per week
b) What was the name of this person's employer, business, agency, or branch of the Armed Forces?
___________________________________
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)
___________________________________
d) Was this mainly?Mark (X) ONE box
[ ] wholesale trade?
[ ] retail trade?
[ ] other (agriculture, construction, service, government, etc.)?
_________________________________
_________________________________
_________________________________
_________________________________
43. 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.)
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.
[ ] No
[ ] No
[ ] Loss
[ ] No
[ ] Loss
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
44. What was this person's total income during the PAST 12 MONTHS?Add entries in questions 43a to 43h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.
[ ] Loss
Continue with the questions for Person 2 on the next page. If no one is listed as person 2 on page 2, SKIP to page 28 for mailing instructions.
(end)