Gambar halaman

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.

Form D-61B

OMB NO. 0607-0856: Approval Expires 12/31/2000


Measuring America

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

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
city or town?
O Yes
O No, outside the city/town limits
Name of county

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?

O NO → Skip to 20a

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

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
Na, Has this person ever served on active duty in

the U.S. Armed Forces, military Reserves, or
National Guard? Active duty does not include training
for the Reserves or National Guard, but DOES include
activation, for example, for the Persian Gulf War.
O Yes, now on active duty

J Yes, on active duty in past, but not now
O No, training for Reserves or National

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
U May 1975 to August 1980
U Vietnam era (August 1964-April 1975)
O February 1955 to July 1964

Korean conflict (June 1950. January 1955)
O World War II (September 1940-July 1947)
O some other time
c. In total, how many years of active-duty military
service has this person had?
O Less than 2 years
O 2 years or more


No o

Because of a physical, mental, or emotional
condition lasting 6 months or more does
this person have any difficulty in doing any of
the following activities:

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

[ocr errors]
[ocr errors]

Oo oo

[ocr errors]
[ocr errors]
[blocks in formation]

Form D-618


Measuring America

« SebelumnyaLanjutkan »