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If you need help completing this form, call 1-800-XXX-XXXX between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free. TDD - Telephone display device for the hearing impaired. Call 1-800-XXX-XXXX between 8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free. ¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario llame al 1-800-XXX-XXXX entre las 8:00 a.m. y las 9:00p.m., 7 dias a la semana. La llamada telefónica es gratis.
The Census Bureau estimates that, for the average household, this form will take about 38 minutes to complete, including the time for reviewing the instructions and answers. Comments about the estimate should be directed to the Associate Director for Finance and Administration, Attn: Paperwork Reduction Project 0607-0856, Room 3104, Federal Building 3, Bureau of the Census, Washington, DC 20233. Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget.
OMB NO. 0607-0856: Approval Expires 12/31/2000
b. Where did this person live 5 years ago? Name of city, town, or post office
a. Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment? O Yes O NO + Skip to 20a
Did this person live inside the limits of the
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?
c. How long has this grandparent been responsible for the(se) grandchild(ren)? If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time.
Less than 6 months 06 to 11 months 0 1 0 2 years O for 4 years
@ years or more
the U.S. Armed Forces, military Reserves, or
J Yes, on active duty in past, but not now
Guard only → Skip to 21 O No, never served in the military Skip to 21 b. When did this person serve on active duty in the U.S. Armed Forces? Mark Wa box for EACH period in which this person served. 0 April 1995 or later
August 1990 to March 1995 (including Persian Gulf War)
September 1980 to July 1990
Korean conflict (June 1950. January 1955)
Because of a physical, mental, or emotional
Yes a. Learning, remembering, or V concentrating?
o | b. Dressing, bathing, or getting around
inside the home? c. (Answer it this person is 16 YEARS OLD
OR OVER.) Going outside the home
alone to shop or visit a doctor's office? 0 d. (Answer if this person is 16 YEARS OLD
OR OVER.) Working at a job or business? O