Form D-Q-GE-AS American Samoa Individual Census Questionnaire

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®

OMB No. 0607-1006: Approval Expires 11/30/2021
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

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).
Please turn to page 2 to begin.

Census Office

County

BCU

Map Spot

Within Map Spot ID

UHE BCU

UHE Map Spot

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
0607-1006, 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 0607-1006” 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-Q-GE-AS (07-27-2019)

11810017

Group Quarters
Administrator

Observation
(TNSOLs only)

Other

Rework

D. JIC1

FORM

Respondent

JIC2

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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

First Name

Yes, Mexican, Mexican Am., Chicano

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.
Address Number (For example: 5007)

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

Street Name (For example: N Maple Ave)

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)
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

Physical Description (if applicable)

Village/Municipality/Estate

ZIP Code

4.

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

5.

Chinese

Female
Some other race – Print race or origin. C

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

Year of birth

years

2

11810025

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

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8.

11.

Where were you born?
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C

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.
NO SCHOOLING COMPLETED
No schooling completed

NURSERY OR PRESCHOOL THROUGH GRADE 12
Nursery school, preschool, or pre-kindergarten

A

Answer question 9 if you were born outside American Samoa.
Otherwise, SKIP to question 10a.

Kindergarten
Grade 1 through 11 – Specify grade 1 – 11

9.

When did you come to live in American Samoa?
If you came to live in American Samoa more than once,
print latest year.

C

12th grade – NO DIPLOMA

Year

HIGH SCHOOL GRADUATE
Regular high school diploma

10.

GED or alternative credential

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.

COLLEGE OR SOME COLLEGE
Some college credit, but less than 1 year of college credit
1 or more years of college credit, no degree

Yes
Associate’s degree (for example: AA, AS)

No ➜ SKIP to question 11

Bachelor’s degree (for example: BA, BS)

b. Was that a public school or college, a private school or
college, or home school?

AFTER BACHELOR’S DEGREE

Public school or public college

Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

Private school or private college or home school

Professional degree beyond a bachelor’s degree
(for example: MD, DDS, DVM, LLB, JD)
Doctorate degree (for example: PhD, EdD)

c. What grade or level were you attending?
Mark K
J ONE box.
I
Nursery school, preschool, or pre-kindergarten

B

Kindergarten
Grade 1 through 12 – Specify grade 1 – 12

Answer question 12 if you have a bachelor’s degree or higher.
Otherwise, SKIP to question 13.

C

12.

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)

13.

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.

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

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14.

18.

What is your ancestry or ethnic origin?

What was your main reason for moving?
Mark K
J ONE box.
I

(For example: Italian, Jamaican, African Am., Cambodian,
Cape Verdean, Norwegian, Dominican, French Canadian,
Haitian, Korean, Lebanese, Polish, Nigerian, Mexican,
Taiwanese, Ukrainian, and so on.)

15.

Employment

To attend school

Military

Family-related

Housing

Natural disaster

Other reason

19.

a. Where was your mother born?
American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C

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.
Yes
No

b. Where was your father born?

20.

American Samoa
Outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C

16.

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

No

a. Insurance through a current or former employer
or union (of yours or another family member)
b. Insurance purchased directly from an insurance
company (by you or another family member)

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

c. Medicare, for people 65 and older, or people
with certain disabilities

Yes
No ➜ SKIP to question 17

d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability

b. What is this language?

e. TRICARE or other military health care
f. VA (enrolled for VA health care)

For example: Korean, Italian, Spanish, Vietnamese.
c. How well do you speak English?

g. Indian Health Service
h. Any other type of health insurance or health
coverage plan – Specify C

Very well
Well
Not well
Not at all

17.

21.

a. Are you deaf or do you have serious difficulty hearing?
Yes

Did you live at this address 5 years ago (on April 1, 2015)?

No

Person is under 5 years old ➜ SKIP to question 19
Yes, this address ➜ SKIP to question 19

b. Are you blind or do you have serious difficulty seeing
even when wearing glasses?

No, different address in American Samoa

Yes

No, outside American Samoa – Print name of U.S. state,
U.S. territory, or foreign country below. C

No

4

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C

26.

How many times have you been married?

Answer questions 22a – c if you are 5 years old or over.
Otherwise, the questionnaire is complete.

Once
Two times

22.

Three or more times

a. Because of a physical, mental, or emotional condition,
do you have serious difficulty concentrating,
remembering, or making decisions?

27.

Yes

In what year did you last get married?
Year

No

b. Do you have serious difficulty walking or climbing
stairs?

E

Yes

Answer question 28 if you are female and 15 years old or over.
Otherwise, SKIP to question 29a.

No

28.

c. Do you have difficulty dressing or bathing?

How many babies have you ever had, not counting stillbirths?
Do not count stepchildren or children you have adopted.

Yes

None or

Number of children

No

29.
D

a. Do you have any of your own grandchildren under the
age of 18 living in this place?

Answer question 23 if you are 15 years old or over. Otherwise,
the questionnaire is complete.

Yes
No ➜ SKIP to question 30

23.

24.

Because of a physical, mental, or emotional condition, do
you have difficulty doing errands alone such as visiting a
doctor’s office or shopping?

b. Are you currently responsible for most of the basic
needs of any grandchildren under the age of 18 who
live in this place?

Yes

Yes

No

No ➜ SKIP to question 30

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.

What is your marital status?
Now married
Widowed

25.

Divorced

Less than 6 months

Separated

6 to 11 months

Never married ➜ SKIP to E

1 or 2 years
3 or 4 years

In the PAST 12 MONTHS did you get –
Yes

No

5 or more years

a. Married?
b. Widowed?
c. Divorced?

5

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30.

34.

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 33a
Only on active duty for training in the Reserves or
National Guard ➜ SKIP to question 32a

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

35.
31.

32.

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.
Car, truck, or private van/bus

September 2001 or later

Public van/bus

August 1990 to August 2001 (including Persian Gulf War)

Taxicab

May 1975 to July 1990

Motorcycle

Vietnam Era (August 1964 to April 1975)

Bicycle

February 1955 to July 1964

Walked

Korean War (July 1950 to January 1955)

Plane or seaplane

January 1947 to June 1950

Boat, ferry, or water taxi

World War II (December 1941 to December 1946)

Worked from home ➜ SKIP to question 43a

November 1941 or earlier

Other method

a. Do you have a VA service-connected disability rating?
Yes (such as 0%, 10%, 20%, ..., 100%)

F

Answer question 36 if you marked "Car, truck, or private
van/bus" in question 35. Otherwise, SKIP to question 37.

No ➜ SKIP to question 33a

36.

b. What is your service-connected disability rating?
0 percent

How many people, including you, usually rode to work in the
car, truck, or private van/bus LAST WEEK?
Person(s)

10 or 20 percent
30 or 40 percent

37.

50 or 60 percent

Hour

70 percent or higher

33.

LAST WEEK, what time did your trip to work usually begin?
Minute

:

a. LAST WEEK, did you work for pay at a job (or
business)?

38.

Yes ➜ SKIP to question 34

b. LAST WEEK, did you do ANY work for pay, even for
as little as one hour?
Yes
No ➜ SKIP to question 39a

6

p.m.

How many minutes did it usually take you to get from home
to work LAST WEEK?
Minutes

No – Did not work (or retired)

a.m.

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G

44.
Answer questions 39 – 42a if you did NOT work last week.
Otherwise, SKIP to question 42b.

39.

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 39c
No

H

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

45.

Yes, on vacation, temporary illness, maternity leave,
other family/personal reasons, bad weather,
etc. ➜ SKIP to question 42a

DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of employment
you had last week.
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).

No ➜ SKIP to question 40

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 41

PRIVATE SECTOR EMPLOYEE

No

40.

Answer questions 45a – f if you worked in the past 5 years
(since 2015). Otherwise, SKIP to question 46.

For-profit company or organization

During the LAST 4 WEEKS, have you been ACTIVELY
looking for work?

Non-profit organization (including tax-exempt and charitable
organizations)

Yes

GOVERNMENT EMPLOYEE

No ➜ SKIP to question 42a

41.

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.)

42.

Owner of incorporated business, professional practice, or farm

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

Worked without pay in a for-profit family business or farm
for 15 hours or more per week

2020
2019 ➜ SKIP to question 43a

b. What was the name of your employer, business,
agency, or branch of the Armed Forces?

2015 to 2018 ➜ SKIP to H
2014 or earlier, or never worked ➜ SKIP to question 46

b. LAST YEAR, 2019, did you work at a job or business at
any time?
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)

Yes
No ➜ SKIP to H

43.

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 44
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

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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?
Yes ➜ What was the amount?

46.

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

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?

$

TOTAL AMOUNT – Dollars

.00

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.

No

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

No

47.

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.

What was your total income for 2019? Add entries in questions
46a to 46h; 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

OR
None

.00
Loss

8

11810082

$

.00
Loss