Government Apps

Census Survey

The Census Survey app is an adaptation of the annual American Community Survey. The census enumerator is able to enter information about the residents of a household and based on the responses given, is presented with pertinent follow-up questions regarding demographics like age, ethnicity, and education, and househould metrics like income, expenditures, and more.

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Census Survey

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Today's Date

Last Name

First Name

Middle Initial

Phone Number

Address

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.

How many people are living or staying at this address?

How many people are living or staying at this address?

Person 1

Last name

First name

Middle Initial

What is Person 1's sex?

What is Person 1’s age?

What is Person 1’s date of birth?

Is Person 1 of Hispanic, Latino, or Spanish origin?

Enter Hispanic, Latino, or Spanish origin

What is Person 1’s race?

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 2

Last name

First name

Middle Initial

How is this person related to Person 1?

What is Person 2's sex?

What is Person 2's age?

What is Person 2's date of birth?

Is Person 2 of Hispanic, Latino, or Spanish origin?

Enter Hispanic, Latino, or Spanish origin

What is Person 2's race?

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 3

Last name

First name

Middle initial

How is this person related to Person 1?

What is Person 3's sex?

What is Person 3's age?

What is Person 3's date of birth?

Is Person 3 of Hispanic, Latino, or Spanish origin?

Enter Hispanic, Latino, or Spanish origin

What is Person 3's race?

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 4

Last name

First name

Middle Initial

How is this person related to Person 1?

What is Person 4's sex?

What is Person 4's age?

What is Person 4's date of birth?

Is Person 4 of Hispanic, Latino, or Spanish origin?

Enter Hispanic, Latino, or Spanish origin

What is Person 4's race?

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

Person 5

Last name

First name

Middle initial

How is this person related to Person 1?

What is Person 5's sex?

What is Person 5's age?

What is Person 5's date of birth?

Is Person 5 of Hispanic, Latino, or Spanish origin?

Enter Hispanic, Latino, or Spanish origin

What is Person 5's race?

Enter the name of enrolled or principal tribe

Enter the name of Asian race

Enter the name of Pacific Islander race

Enter the name of race

If there are more than five people living or staying here, you may receive a call for more information about them.

Person 6

Last name

First name

Middle initial

What is Person 6's sex?

What is Person 6's age?

Person 7

Last name

First name

Middle initial

What is Person 7's sex?

What is Person 7's age?

Person 8

Last name

First name

Middle initial

What is Person 8's sex?

What is Person 8's age?

Person 9

Last name

First name

Middle initial

What is Person 9's sex?

What is Person 9's age?

Person 10

Last name

First name

Middle initial

What is Person 10's sex?

What is Person 10's age?

Person 11

Last name

First name

Middle initial

What is Person 11's sex?

What is Person 11's age?

Person 12

Last name

First name

Middle initial

What is Person 12's sex?

What is Person 12's age?

Housing

Which best describes this building?

About when was this building first built?

When did PERSON 1 move into this house, apartment, or mobile home?

How many acres is this house or mobile home on?

IN THE PAST 12 MONTHS, what were the actual sales of all agricultural products from this property?

Is there a business (such as a store or barber shop) or a medical office on this property?

How many separate rooms are in this house, apartment, or mobile home?

How many of these rooms are bedrooms?

Does this house, apartment, or mobile home have -

How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?

Which FUEL is used MOST for heating this house, apartment, or mobile home?

LAST MONTH, were you charged for electricity for this house, apartment, or mobile home?

LAST MONTH, what was the cost (in USD) of electricity for this house, apartment, or mobile home?

LAST MONTH, were you charged for gas for this house, apartment, or mobile home?

LAST MONTH, what was the cost (in USD) of gas for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, were you charged for water and sewer for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, what was the cost (in USD) of water and sewer for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, were you charged for oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, what was the cost (in USD) of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home?

IN THE PAST 12 MONTHS, did anyone in this household receive Food Stamps or a Food Stamp benefit card?

Is this house, apartment, or mobile home part of a condominium?

What is the monthly condominium fee (in USD)?

Is this house, apartment, or mobile home –

What is the monthly rent for this house, apartment, or mobile home?

Does the monthly rent include any meals?

You or someone else in this household OWNS or IS BUYING this house, apartment, or mobile home

About how much (in USD) do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale?

What are the annual real estate taxes on THIS property?

What is the annual payment for fire, hazard, and flood insurance on THIS property?

Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?

How much is the regular monthly mortgage payment on THIS property?

Does the regular monthly mortgage payment include payments for real estate taxes on THIS property?

Does the regular monthly mortgage payment include payments for fire, hazard, or flood insurance on THIS property?

Do you or any member of this household have a second mortgage or a home equity loan on THIS property?

How much (in USD) is the regular monthly payment on all second or junior mortgages and all home equity loans on THIS property?

What are the total annual costs (in USD) for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site?

About Person 1

Where was Person 1 born?

Print name of foreign country, or Puerto Rico, Guam, etc.

Is this person a citizen of the United States?

Enter year of naturalization

When did this person come to live in the United States?

At any time IN THE LAST 3 MONTHS, has this person attended school or college?

What grade or level was this person attending?

Specify grade 1 – 12

What is the highest degree or level of school this person has COMPLETED?

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)

What is this person’s ancestry or ethnic origin?

Does this person speak a language other than English at home?

What language, other than English, is spoken at home

How well does this person speak English?

Did this person live in this house or apartment 1 year ago?

Enter name of foreign country, or U.S. Virgin Islands, Guam, etc. lived in 1 year ago

Where did this person live 1 year ago?

Address (Number and street name)

Name of city, town, or post office

Name of U.S. county or municipio in Puerto Rico

Name of U.S. state or Puerto Rico

ZIP code

Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans?

Enter name of other type of health insurance or health coverage plan

Is this person deaf or does he/she have serious difficulty hearing?

Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

Person is 5 years old or over

Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

Does this person have serious difficulty walking or climbing stairs?

Does this person have difficulty dressing or bathing?

Person is 15 years old or over

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?

What is this person’s marital status?

Currently or was married

In the PAST 12 MONTHS did this person get -

How many times has this person been married?

In what year did this person last get married?

Has this person given birth to any children in the past 12 months?

Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?

Is this grandparent currently responsible for most of the basic needs of any grandchildren under the age of 18 who lives in this house or apartment?

How long has this grandparent been responsible for these grandchildren?

Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?

When did this person serve on active duty in the U.S. Armed Forces?

Does this person have a VA service-connected disability rating?

What is this person’s service-connected disability rating?

LAST WEEK, did this person work for pay at a job (or business)?

LAST WEEK, did this person do ANY work for pay, even for as little as one hour?

Person worked last week

At what location did this person work LAST WEEK?

Address (Number and street name)

Name of city, town, or post office

Is the work location inside the limits of that city or town?

Name of county

Name of U.S. state or foreign country

Name of foreign country, outside of the United States

ZIP Code

How did this person usually get to work LAST WEEK?

Worked outside of the home

How many people, including this person, usually rode to work in the car, truck, or van LAST WEEK?

What time did this person usually leave home to go to work LAST WEEK?

Hour

Minute

a.m. or p.m.

How many minutes did it usually take this person to get from home to work LAST WEEK

Person did not work last week

LAST WEEK, was this person on layoff from a job?

LAST WEEK, was this person TEMPORARILY absent from a job or business?

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?

During the LAST 4 WEEKS, has this person been ACTIVELY looking for work?

LAST WEEK, could this person have started a job if offered one, or returned to work if recalled?

When did this person last work, even for a few days?

During the PAST 12 MONTHS (52 weeks), did this person work 50 or more weeks? Count paid time off as work.

How many weeks DID this person work, even for a few hours, including paid vacation, paid sick leave, and military service?

During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did this person usually work each WEEK?

Current or most recent job activity

Was this person -

Is this person on active duty in the Armed Forces?

Enter the branch of the Armed Forces

Name of company, business, or other employer person worked for

What kind of business or industry was this?

Is this mainly –

What kind of work was this person doing?

What were this person’s most important activities or duties?

Income in the past 12 months

Select "Yes" 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.) Select "No" to show types of income NOT received. If net income was a loss, select "Yes, loss" and enter 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 select "No" for the other person.

Wages, salary, commissions, bonuses, or tips from all jobs.

Total amount for past 12 months

Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships.

Total gain amount for past 12 months

Total loss amount for past 12 months

Interest, dividends, net rental income, royalty income, or income from estates and trusts.

Total gain amount for past 12 months

Total loss amount for past 12 months

Social Security or Railroad Retirement.

Total amount for past 12 months

Supplemental Security Income (SSI).

Total amount for past 12 months

Any public assistance or welfare payments from the state or local welfare office.

Total amount for past 12 months

Retirement, survivor, or disability pensions.

Total amount for past 12 months

Any other sources of income received regularly such as Veterans’ (VA) payments, unemployment compensation, child support or alimony.

Total amount for past 12 months

Was this person’s total income during the past 12 months a gain or a loss?

Total gain amount for past 12 months

Total loss amount for past 12 months