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(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
Wholesale 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
State government employee
Local government employee (city, county, etc.).

Self-employed in own business,
professional practice, or farm

Own business not incorporated
Own business 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)
Name of Person 1

15a. Did this person live in this house (or dwelling) 1 year 18a. During the last 12 months, where did this person
ago (April 1, 1979)?

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
Last name
First name
Middle initial 2(Yes, this house

[ I Indian Health Service (IHS)
SKIP TO 16

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,
5. On another reservation
(Name of tribe)

or city clinic or hospital

7
None - SKIP 10 12a

(a)
(Reservation)

6C I Did not seek health care - SKIP to 20

-P3

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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,
or making things to sell or trade?

[ Now working
2: 1980
31 .1979

Continue with 25.
* 1978
5C 1975 10 1977

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
as rugs, pottery, or jewelry?
31 Yes - Continue with 210

1.NO - SKIP 10 23 c. Did this person earn any cash income from this work

in 1979?

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5. Yes

6
1974 or earlier

SKIP TO 28
Never worked
25 - 27. Current or most recent job activity

Describe clearly this person's chiel job activity
or business last week.
11 this person had more than one job, describe
the one at which this person worked the
most hours.
11 this person had no 100 or business last week.
give information for last job or business
since 1975.

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

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h. Bureau of Indian Allails general

assistance.

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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.

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29. What was this person's total income in 1979?

Print the dollar amount in the space provided.
11 total income was a loss, mark the "Loss"
box and enter dollar amount. 11 total amount is
zero, mark the "None" box. Il exact amount is
not known, give best estimate.

Include any income from (before deductions for
taxes, bonds, dues, or other items)

• Wages or salaries
• Own farm or nonfarm business, partnership

or professional practice inel after expenses)
• Interest, dividends, or net rental income
• Social Security or Railroad Retirement
• Public assistance or welfare
• Unemployment compensation, veterans'

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)

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HI. Did you leave anyone out of Question 1 because you were not sure H9. Is this apartment (house) part of a condominium?
if the person should be listed – for example, a new baby still in the

No
hospital, o lodger who also has another home, or a person who stays here

Yes, a condominium
once in a while and has no other home?

H10. If this is a one-family house
Yes

- On page 20 give name(s) and reason left out.
No

a. Is the house on a property of 10 or more acres?
Yes

No
H2. Did you list anyone in Question 1 who is away from home now
for example, on a vocation or in a hospital?

b. Is any part of the property used as a
Yes -

commercial establishment or medical office?
On page 20 give nomne(s) and reason person is away.
No

Yes

No

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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
On a place of 1 to 9 acres?
On a place of 10 or more acres?

b. Last year, 1979, did sales of crops, livestock, and other farm products
from this place amount to -
Less than $50 (or None)

$250 to $599 $1,000 to $2,499
$50 to $249

$600 to $999

$2,500 or more

H22. What are the costs of utilities and fuels for your living quarters?
a. Electricity
$

00 OR

Included in rent or no charge

Electricity not used
Average monthly cost
b. Gas
$

00 OR

Included in rent or no charge

Gas not used
Average monthly cost
c. Water
$

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
Yearly cost
H23. Do you have complete kitchen facilities? Complete kitchen facilities
are a sink with piped water, a ronge or cookstove, and a refrigerator,
Yes

No

H16. Do you get water from –

A public system (city water department, etc.) or private company?
An individual drilled well?
An individual dug well?
Some other source (a spring, creek, river, cistern, etc.)?

H17. Is this building connected to a public sewer?

Yes, connected to public sewer
No, connected to septic tank or cesspool
No, use other means

H24. How many bedrooms do you have?
Count rooms used mainly for sleeping even if used also for other purposes.
No bedroom
2 bedrooms

4 bedrooms
1 bedroom
3 bedrooms

5 or more bedrooms

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No

H20. How are your living quarters heated?

H27. Do you have air conditioning?
Fill one circle for the kind of heat used most.

Yes, a central air-conditioning system
Steam or hot water system

Yes, 1 individual room unit
Central warm air furnace with ducts to the individual rooms

Yes, 2 or more individual room units
(Do not count electric heat pumps here)
Electric heat pump
Other built-in electric units (permanently installed in wall, ceiling,

H28. How many automobiles are kept at home for use by members or boseboard)

of your household?
None

2 automobiles
1 automobile

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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