(Name of company, business, organization, or other employer) b. What kind of business or industry was this? Describe the activity at location where employed. (For example: Hospital, newspoper publishing, mail order house, outo engine manufacturing, breakfast cereal manufacturing) c. Is this mainly (Fill one circle) Manufacturing i Retail trade Other – (agriculture, construction, service, government, etc.) 29. Occupation a. What kind of work was this person doing? c. Own farm Report net income after operating expenses. Include earnings as a tenant farmer or sharecropper, Yes 00 No (Annual amount - Dollars) d. Interest, dividends. royalties, or net rental income ... Report even small amounts credited to an account. Yes → 00 No (Annual amount Dollars) e. Social Security or Railroad Retirement Yes 00 No (Annual amount - Dollars) 1. Supplemental Security (SSI), Aid to families with Dependent Children (AFDC), or other public assistance or public welfare payments Yes → 00 No (Annual amount Dollars) g. Unemployment compensation, veterans' payments. pensions alimony or child support, or any other sources of income received regularly Exclude lump-sum poyments such as money from an inheritance or the sale of a home. (For example: Registered nurse, personnel manager, supervisor of order department, gasoline engine assembler, grinder operator) b. What were this person's most important activities or duties? (For example: Patient core, directing hiring policies, supervising order clerks, assembling engines, operating grinding mill) 30. Was this person – (Fill one circle) Employee of private company, business, or individual, for wages, salary, or commissions Federal government employee Self-employed in own business, Own business not incorporated Yes 00 No (Annual amount - Dollars) 33. What was this person's total income in 1979? Add entries in questions 320 $ 00 through g, subtract any losses. (Annual amount Il totol amount was a loss, Dollars) write "Loss" above amount. OR None Working without pay in family business or farm SUPPLEMENTARY QUESTIONNAIRE FOR INDIAN RESERVATIONS (POPULATION) 15a. Did this person live in this house (or dwelling) 1 year 18a. During the last 12 months, where did this person usually seek health care? Read each category and mark one box for the source used most often, [ Born April 1979 or later – SKIP 10 17 [ I Indian Health Service (IHS) clinic, health center or hospital 10. What is this person's tribe? Report tribe in which CiNo, different house - Continue with 150 21 | Tribal clinic or hospital enrolled. It not enrolled, report principal tribe. d. Where did this person live 1 year ago (April 1, 1979)? Continue 3C) Private physician or dentist with 186 *[ On this reservation *L.Government (Federal, State, county, or city clinic or hospital 7 (a) 6C I Did not seek health care - SKIP to 20 -P3 5 5[7 Other 1 2 i. Other FORM D 19 1910.707 SUPPLEMENTARY QUESTIONNAIRE FOR INDIAN RESERVATIONS (POPULATION)-Continued 28. In 1979, did this person receive benelits from any of these programs? Mark one box for each category. 24. When did this person last work, even for a few days, at a job, business, farm, raising crops and/or livestock, [ Now working Continue with 25. Yes No 1 2la. Last year (1979), did this person work, even for a few days, at a paid job or in a business or farm? o Yes - SKIP 10 210 -2[] No - Continue with 210 b. In 1979, did this person raise crops and/or livestock, or spend any time making things to sell or trade such 1.NO - SKIP 10 23 c. Did this person earn any cash income from this work in 1979? 12 5. Yes 6 SKIP TO 28 Describe clearly this person's chiel job activity e. Social Security (green-colored check). o No I. Supplemental Security.U.S. Government (gold-colored check) . . . d. How many weeks did this person work in 1979? include work at a paid job or business as well as time spent raising crops and/or livestock or making things to sell or trade. irilo 13 weeks 2 14 to 26 weeks Continue with 22 27 to 39 weeks 3 h. Bureau of Indian Allails general assistance. i. Other assistance or welfare payments. 22. What was the main reason this person worked fewer than 50 weeks in 1979? Read each calegory and mark one box. 29. What was this person's total income in 1979? Print the dollar amount in the space provided. Include any income from (before deductions for • Wages or salaries or professional practice inel after expenses) payments, pensions, alimony or child support, or any other money income received regularly Exclude lump-sum amounts such as gains from the sale of properly. (For example High school English teacher, typist, practical nurse, carpenter, rug weaver, shee pherder) 7 HI. Did you leave anyone out of Question 1 because you were not sure H9. Is this apartment (house) part of a condominium? No Yes, a condominium H10. If this is a one-family house - On page 20 give name(s) and reason left out. a. Is the house on a property of 10 or more acres? No b. Is any part of the property used as a commercial establishment or medical office? Yes No b. Is there a passenger elevator in this building? Yes No H15a. Is this building On a city or suburban lot, or on a place of less than 1 acre? - Skip to H16 b. Last year, 1979, did sales of crops, livestock, and other farm products $250 to $599 $1,000 to $2,499 $600 to $999 $2,500 or more H22. What are the costs of utilities and fuels for your living quarters? 00 OR Included in rent or no charge Electricity not used 00 OR Included in rent or no charge Gas not used 00 OR Included in rent or no charge Yearly cost d. Oil, coal. kerosene, wood. etc. $ 00 OR Included in rent or no charge These fuels not used No H16. Do you get water from – A public system (city water department, etc.) or private company? H17. Is this building connected to a public sewer? Yes, connected to public sewer H24. How many bedrooms do you have? 4 bedrooms 5 or more bedrooms No H20. How are your living quarters heated? H27. Do you have air conditioning? Yes, a central air-conditioning system Yes, 1 individual room unit Yes, 2 or more individual room units H28. How many automobiles are kept at home for use by members or boseboard) of your household? 2 automobiles 3 or more automobiles Floor, wall, or pipeless furnace Room heaters with flue or vent, burning gas, oil, or kerosene H29. How many vans or trucks of one-ton capacity or less are kept at Room heaters without flue or vent, burning gas, oil, or kerosene (not portable) home for use by members of your household? Fireplaces, stoves, or portable room heaters of any kind None 2 vans or trucks No heating equipment I van or truck 3 or more vans or trucks |
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