Gambar halaman
PDF

Please answer questions

10,11, and 12 at the

bottom of page 2. A. How many living quarters, occupied and vacant,

at this address?

[blocks in formation]
[merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small]
[merged small][merged small][merged small][ocr errors][ocr errors][ocr errors][merged small]

H9. Are your living quarters—

C Owned or being bought by you or by someone e^se

in this household? Do not include cooperatives and

condominiums here.
n A cooperative or condominium which is owned or being

bought by you or by someone else in this household?
O Rented for cash rent?
,•': Occupied without payment of cash rent?

HlOa. Is this building a one-family house?
O Yes, a one■family house
O No, a building for 2 or more families
or a mobile home or trailer

b. // "Yes"— Is this house on a place of 10 acres or more,
"~ or is any part of this property used as a commercial

establishment or medical office?
O Yes, 10 acres or more

O Yes, commercial establishment or medical office
O No, none of the above

\ Hll. If you live in a one■family house which

you own or are buying

What is the value of this property; that is, how much

do you think this property (house and lot) would sell for

if it were for sale?

O Less than $5,000
O $5,000 to $7,499
O $7,500 to $9,999

$10,000 to $12,499
$12,500 to $14,999
$15,000 to $17,499
$17,500 to $19,999

0 $20,000 to $24,999

0 $25,000 to $34,999

O $35,000 to $49,999

O $50,000 or more

// this house is on a place of 10 acres or more, or if any part of this property is used as a commercial establishment or medical office, do not answer this question.

HI 2. Answer this question if you pay rent for your living quarters. a. // rent is paid by the month—

What is the monthly rent?

Write amount here

O Less than $30

O $30 to $39

O $40 to $49

O $50 to $59

O $60 to $69
O $70 to $79
O $80 to $89 |
0 $90 to $99

O $100 to $119
O $120 to $149
O $150 to $199
C $200 to $249
O $250 to $299
O $300 or more

.00 (Nearest dollar)

b. If rent is not paid by the month

What is the rent, and what period of time does it cover?

$ .00 per

/Nearest dollar)

{Week, Z*lfmontb~,~Tear~etc~}

[merged small][ocr errors][merged small][merged small][merged small][merged small][ocr errors]
[ocr errors]

tbii margin

[merged small][ocr errors]
[merged small][table][ocr errors][ocr errors][merged small]

The 15-percent torn contains the questions shown on page 4. The 5-perceat torn coRtafns the questices shown in fte fkst col unit oi page 4 and the qaeriioatt on pate 5.

H24a. How many stories (floors) are in this building?

0 1 to 3 stories
i 0 4 to 6 stories

r< O 7 to 12 stories
'13 stories or more |

h, !f 4 or more itories

Is there a passenger elevator in this building?

0 Yes O No

H25a. Which fuel is used most for cooking?

I From underground pipes

Gas serving the neighborhood. O Coat or coke Q

I Bottled, tank, or LP O Wood O

Electricity O Other fuel .. O

Fuel oil, kerosene, etc O No fuel used O

b. Which fud is used most for house heating?

1 From underground pipes

Gas serving the neighborhood. O Coal or coke O

'Bottled, tank, or LP O Wood O

Electricity O Other fuel . ■ 0

Fuel oil. kerosene, etc O No fuel used O

c. Which fud is used most for water heating7

i From underground pipes

Gas serving the neighborhood. O Coal or coke O

1 Bottled, tank, or LP O Wood O

Electricity O Other fuel .. O

Fuel oil, kerosene, etc O No fuel used O

H26. How many bedrooms do you have?

Count rooms used mainly for sleeping even if used also for other purposes.
O No bedroom O 3 bedrooms

O 1 bedroom £ O 4 bedrooms

O 2 bedrooms 0 5 bedrooms or more

H27a. Do you have a clothes washing machine?
O Yes, automatic or semi■automatic
O Yes, wringer or separate spinner
O No

b. Do you have a clothes dryer?

O Yes. electrically heated

O Yes. gas heated

0 No |

c Do you have a dishwasher (built-in or portable)! O Yes O No

d. Do you have a home food freezer which is separate from your refrigerator?

O Yes O No

H28a. Do you have a television set? Count only sets in working order.
O Yes, one set
O Yes, two or more sets
O No

b. // "Yes"— Is any set equipped to receive UHF broadcasts,
that iv channels 14 to 83?

O Yes O No ■

H29. Do you have a battery-operated radio?

Count car radios, transistors, and other battery-operated sets in working
order or needing only a new battery for operation.
O Yes, one or more O No

H30. Do you (or any member of your household) own a second home or other living quarters which you occupy sometime during the year?

O Yes O No

[merged small][graphic]
[merged small][ocr errors]
[merged small][merged small][merged small][merged small][ocr errors][ocr errors][merged small][ocr errors][ocr errors][merged small][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][merged small][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][graphic][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][merged small]
[merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small]

(Forexample: Afro-Amer., English, French, German, Honduran, Hungarian, Irish, Italian, Jamaican, Korean, Lebanese, Mexican, Nigerian, Polish, Ukrainian, Venezuelan, etc.)

15a. Did this person live in this house five years ago
(April 1, 1975)?

If In college or Armed Forces In April 7975, report place
of residence there.

O Born April ]975 or later - Turn to next page for
next person
C Yes, this house - Skip to 16

r~ O No, different house

b. Where did this person live five years ago (April 1, 1975)?

(1) State, foreign country,

Puerto Rico, .— Guam, etc.:

(2) County:

(3) City, town,

village, etc.:

(4) Inside the incorporated (legal) limits
of that city, town, village, etc.?

O Yes O No, in unincorporated area

b. Was active duly military service during —

Fill a circle for each period in which this person served.

O May 1975 or later

O Vietnam era (August 1964-Aprtl 1975)

O February 1955-July 1964

O Korean conflict (June 1950-fanuory 1955)

C World War II (September 1940-July 1947)

| O World War I (April 1917-November 1918)

O Any other time

19. Does this person have a physical, mental, or other health condition which has lasted for 6 or more months and which

Yes t<

a. limits the kind or amount

of work this person can do at a lob? o

b. Prevents this person from working at a lob? O

c. Limits or prevents this person

from using public transportation?"'

20. If thls person Is a female - None 1 2 3 4 5 6

How many babies has she ever Q O O O O O O had, not counting stillbirths?

Do not count her stepchildren or children she has adopted.

[ocr errors]
[merged small][ocr errors][merged small][merged small][merged small][merged small][ocr errors][merged small][ocr errors][merged small]

0 Yes-Fillthisctrcltifthis 0

person worked full

■■ time or port time.

(Countpart-time work
such as delivering papers,
or helping without pay in
a family business or farm.
Also count active duty
in the Armed Forces,)

Skip to 25

No - Fill this ctrclt if this person did not work, or did only own housework, school work, or volunteer work.

b. How many hours did this person work last week (at all lobs)?

Subtract any time off; add overtime or extra hours worked.

Hours

23. 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.

If one location cannot be specified, see instructlon guide. a. Address (Number and street)

If street address is not known, enter the building name, shopping center, or other physical location description.

b. Name of city, town, village, borough, etc.

c. Is the place of work inside the incorporated (legal) limits of that city, town, village, borough, etc.?

O Yes O No, in unincorporated area

d. County

e. State

24a. Last week, how long did it usually take this person to get from home to work (one way)?

Minutes

b. How did this person usually get to work last week? If this person used more than one method, give the one usually used for most of the distance.

O Car C

O Truck H °

C Van O

O Bus or streetcar O

O Railroad O

O Subway or elevated O

// car, truck, or von in 24b, go to 24c.

Otherwise, skip to 28.

Taxicab
Motorcycle
Bicycle
Walked only
Worked at home
Other - Specify -

^S^^^^^^^gS^^^^^^^S

[ocr errors][ocr errors][ocr errors][ocr errors]

9 9 9

9 9 9

9 9 9

[ocr errors][ocr errors][ocr errors][ocr errors][ocr errors][ocr errors]
[merged small][ocr errors]
« SebelumnyaLanjutkan »