13a. FIELD REPRESENTATIVE CHECK ITEM

9. ADDRESS (Sheet Line )

9a. What is your (the) exact address?9b. Is this also your (the) mailing address?

House No., Street, Apt. No., or other identificationPlace State ZIP CodeRoute No., PO Box, or other identificationPlace State ZIP Code

9c. Group Quarters name 9d. Type code 9e. Sample number

Yes No – Specify below

017

2. Control number 3a. HH 

No.

3b. CU 

No.

PSUcode

Segmentnumber

Segmentnumbersuffix

Sampledesignation

Serialnumber

Serialnumbersuffix

4. Segment type 5a. Status of unit

1234

UnitPermitAreaGroupQuarters

Serial no.assignedby Wash.Serial No.assignedby R.O.

010 011 1

2

5b. Letter sent

1 Yes 2 No

7a. Extra 

unit

001 002

D

006

6. Earliest placement date

AREA SEGMENTS ONLY

012 Month Date

7b. Sheet 7c. Extra 

unit No

12. LAND USE – Follow in

10. YEAR BUILT

Ask first visitDO NOT ask

When was thisstructureoriginally built?

Before 4-1-90

Continue

interview

After 4-1-90Complete item

11c when

required; end

interview

11. COVERAGE QUESTIONS

Ask items that are markedDO NOT ask

a.b.c.

Are there any occupiedor vacant living quartersbesides your own in thisbuilding?Are there any occupiedor vacant living quartersbesides your own on thisfloor?Is there any otherbuilding on this propertyfor people to live in –either occupied orvacant?

Y N

Fill

Table X

Y N

Fill

Table X

Y N

Fill

Table X

12a.

018 1

2

019

Urban – Go to Rural

– Regular u

coded 92–

– Group Qu

item 9d – 

then go to 

12b. During the past 12 

livestock, and otheplace amount to $

12

YesNo

13. CLASSIFICATION OF LIVING QUARTERS – Mark by observation

020

Unit is –

In a Group Quarters – Refer to the

CE-350.1 and mark the appropriate

box in either item 13c or item 13d.

NOT in a Group Quarters

12

13b. ACCESS

021 1 Direct – Go to item 13c

Through another unit –Not a separate HU;

combine with unit

through which access is

gained. (Apply merged

unit procedures if

appropriate.)

2

13c. HOUSING unit

023 1 House, apartment, flat

2 HU, in nontransient hotel, motel, etc.

HU, permanent in transient hotel,motel, etc.HU, in rooming house

Mobile home or trailer with NOpermanent room addedMobile home or trailer with one ormore permanent rooms addedHU not specified above – Describe in

"NOTES."

34

567

13d. Group Quarters unit

89

Quarters not HU boarding house

10

Student quarters dormitoryGroup Quarters uabove – Describe 

15. WEEK 1 PLACEMENT

PERIOD

Earliest date Latest date

1 00123456789

101112

003005007009011013015017019021023

Call

(a)

Reason

(Enter code)

(b)

Field Representative Name

(c)

16. RECORD OF TELEPHONE CONTACT AND REASON FOR CONTACT

Enter code for reason of telephone contact from list. 1 Telephone call to collect data

2 Telephone call to schedule appointment3 Other telephone call

002004006008010012014016018020022024

Field Representative 

code

(d) (e)

SUPERVISOR’S USE 

R – Reint. O – Obs.

Field Representative 

code

19. DIARY START DATES

WEEK 1

005

Through

From

006

WEEK 2

From

Through

007008

Month Date YearMonth Date YearMonth Date YearMonth Date Year

17. RECORD OF TRAVEL TIME (See page 20)

18. RECORD OF INTERVIEW AND OFFICE ACTIVITY TIME (See page 20)

20. FINAL INTERVIEW STATUS – Enter the appropriate code (01–19) f

Type AType BType C

Code01 – Diary placed or completed

NONINTERVIEW CODES

02 – No one home (unable to contact)03 – Temporarily absent during ENTIRE

reference week

04 – Refused05 – Other – Specify

06 – Vacant (for rent)07 – Vacant (for sale)08 – Vacant (other)09 – Occupied by persons with URE10 – Under construction, not ready11 – Other – Specify12 – Demolished13 – House or mobile home moved14 – Converted to permanent nonresidential use15 – Merged16 – Condemned17 – Located on military base (post)18 – CU moved19 – Other – Specify

003 004 005 007 008 009

009010011012013014015016

DIAR

C

If code is 0If code is 0number of tenure cod

DI

If code is 0

Mark (X) ap

WhiteBlackAmerAsian 

1234

CompPartiaTotal 

C

123

1. Regional

Officecode

lll

ll

ll

lllll

lllll

ll

ll

lllll

lllll

ll

ll

lllll

lllll

ll

ll

lllll

lllll

lll

lllllllll

lllllllll

lllllllll

lllllll

lllllllll

llll

Checkdigit

0075

lllllllll

SEGMENTI

SEGSUFF

SA MP_DES

A LPHA SUF

CHECK

REG_OFF

A REA CODE

HH_NUM

CU_NUM

SEGTYPE

DA YPLA CE

A DDRTYPE

DIRA CC

DESCRIP

STRTMNTH

STRTDA Y

STRTYEA R

ENDDA TE

TENU

HH_ME

PH_CA L

FR_COD
1.

201

FORM CE-802 (1-1-98)© Section 1 – HOUSEHOLD CHARACTERISTICS

PROCESSING USE ONLY

PERSON LINE NUMBER

©

Code Mo. Date

202203204205206207208209210211212213214215

010203040506070809101112131415

WEEK 2

PLACEMENT

ONLY

2. STATUSEnter code

and date

change

occurred

1 – Deletion2 – Addition

3. HOUSEHOLD ROSTER

(last name first)What are the names ofall persons living orstaying here? Start withthe name of the personor one of the personswho owns or rents thishome.

List all persons who usually

live here and all persons

who are temporarily

absent. Be sure to include

infants under 1 year of age.

HOUSEHOLD RECORD – FILL ITEMS 2–7b FOR ALL PERSONS LIVING OR STAYING HERE.

4. RELATIONSHIP TO REFERENCE

PERSON

Ask if not apparent.What is . . .’s relationshipto (reference person)?

Example: Reference person,husband, wife, son,daughter-in-law, partner, lodger,lodger’s wife, etc.

Week 1 Week 2

HH

code

CU

code

CU

code

HH

code

GO TO ITEM 5a Male Female

6. SEXAsk if not

apparent

Is . . .male orfemale?

1 21 21 21 21 21 21 21 21 21 21 21 21 21 21 2

7a. AWAY AT

COLLEGE

Ask if not

apparent.

Are any ofthese personsliving away atcollege?

If YES is marked

below for a

person, mark

NO, in item 7b

without asking.

YES NO YES NO

7b. HOUSEHOLD

MEMBER

Does . . .usuallylive here?If NO,

probe for

URE

GO TO ITEM 8a

111111111111111

111111111111111

222222222222222

222222222222222

8g.

CONSUMER UNIT NUMBER

Read

item

8f on

next

page

9. BIRTH DATE/AGEWhat is . . .’s dateof birth?Verify age using

information booklet.

Example: 01-20-1983 

12-01-1924

Mo. Date Year Age

10Sh

inf

bo

pag

Whthof pethEn

co

fro

be

ASK AT WEEK 1 PLACEMENT.

5a. I have listed . . . (Read names from item 3.)

Have I missed –

– any babies or small children? .....................

– anyone else staying here?........................

YES NO

– anyone who usually lives here but is away now –

traveling, at school, or in a hospital? ...............

– any lodgers, boarders, or persons you employ

who live here ? ................................

If "YES", ask

name and

record in

roster above

(item 3).

Go to item

6 above



ASK AT WEEK 2 PLACEMENT.

5b. I have listed . . . (Read names from item 3.)

Are all of these persons still living or staying here?....

YES NO

If "NO", ask:

5c. Who no longer lives here?5d. Is anyone else living or staying here, 

including newborn babies? ......................

If "YES", ask name and record in roster above (item 3).

Enter code "2" in item 2 and complete items 4–14 for all

persons as appropriate.

Go to

section 1,

item 17a

For each person who has left the household, enter a

code "1" in item 2.



HOUSING UNIT COVERAGEFIELD REPRESENTATIVE CHECK ITEM

8a. Unit is –

In a Group Quarters – Go to item 8d

NOT in a Group Quarters– Go to item 8b

Ask if not apparent.

8b. Do all the persons in this household

live OR eat together?

YesNo – Neither live nor eat together –

Fill Table X (page 15) for the person

or group of persons not living or

eating with the reference person.

Ask if not apparent.

8c. Does any other household on

the property live OR eat withthis household?

Yes – Redefine the unit to include

space occupied by all persons who

live or eat together (apply merged

unit procedures if appropriate).

No – Go to item 8d

8d. FIELD REPRESENTATIVE

CHECK ITEM FOR ASSIGNINGCU NUMBERS

Include anyone who is a household member at

time of interview.

Household contains only the reference person or others related to thereference person by blood, marriage, adoption, or other legalarrangements – Enter "1" in item 8g above for all household members.

Go to item 8f on page 3.

Household contains oneor more persons not related to the referenceperson by blood, marriage, adoption, or other legalarrangements – Go to item 8e on page 3

12

231

1 2 3 4 5 

Perline 

© FILL ITEMS 8g – 14 ONLY FOR M

MEMBNO

STA TDA TE

HH_CODE1

 CU_CODE1

SEX

A WA Y_COL

HH_MEM

BIRTH_MO

BIRTH_DY

BIRTH_YR

A GE
FORM CE-802 (1-1-98)© Section 1 – HOUSEHOLD CHARACTERISTICS – Continued

8e.

Ask first for reference person and all others related to

reference person by blood, marriage, adoption or other legal

arrangement. Then ask for each other person or group of

related persons.

(1) Do(es) . . . pay for all . . . housing expenses with . . .

own money?

(2) Do(es) . . . pay for all . . . food expenses with . . .

own money?

(3) Do(es) . . . pay for all . . . other living expenses

such as clothing, transportation, etc., with . . .own money?

FIELD REPRESENTATIVE CHECK ITEMAre two or more "YES" boxes marked in items 8e, 1–3?

8e.(4) Does all or part of the money to pay for . . . (Specify

expenses with NO marked in items 8e, 1–3) come from

someone in this household?

(5) Who is (are) that (these) person(s)?FINANCIAL RESPONSIBILITY

NOTE – If more than 4 CU’s, stop interview. List the CU’s on an INTER-COMM and call your office.

8f. FIELD REPRESENTATIVE INSTRUCTION – Consumer Unit

Read to respondent: During this interview, I will use the words consumer unit or CU. A consumer unit is the (person/group of related persons) in this

household who (is/are) independent of all other persons in this household for payment of their major expenses.The person(s) I’m including in your CU (is/are) – Read names of all persons listed in item 3 with the same CU marked in item 8g. Go to item 9 on previous page.

FIELD REPRESENTATIVE CHECK ITEMDoes this household contain more than one CU?

Yes – Go to item 15a

No – Go to item 16a

15a. Does more than one person in this household regularly contribute to the

expense of items such as food, cleaning supplies, or paper products?

Yes – Go to item 15b

No – Go to item 16a

16a. Are these living quarters used partly for business or rented to others?

No – Go to section 2

Part businessRented to othersBoth business and rented to others

12121234

17a.

ASK AT WEEK 1 AND WEEK 2 PICK-UPWere any CU members away overnight for one day or morelast week (during the diary reference period)? .............If "YES" – Which persons?Enter line numbers

b. Did anyone else, such as visitors, stay here overnight

for one day or more last week (during the diary referenceperiod)? ...........................................

If "YES" – How many such persons?Enter the number of persons.

330333

b. Does one person usually make the purchases?

YesNo – Go to item 16a

If "YES" – Who? Enter line number

NOTE – If "YES", ask the person who usually makes the

purchases to record the expenses for the shared items.

What percent of the expenses is counted as a businessexpense?

Percent

12

331332

b.

334 .00

335 1

2

YesNo

336 X All337 338 339343 1

2

YesNo

Persons 344

WEEK 1 WEEK 2

lll

lll

lll

lll

311 

Line No.(s)

YesNo

312314317 1

2

YesNo

318 1

2

YesNo

319 1

2

320 1

2

321 1

2Assign to same CU in it

322323

Line No.(s)

311 03

Line No.(s)

YesNo

312314317 1

2

YesNo

318 1

2

YesNo

319 1

2

Yes – Assign next available

CU No. in item 8g

No – Ask item 8e (4)

320 1

2

Yes – Ask item 8e (5)No – Assign next available

CU No. in item 8g

321 1

2Assign to same CU in item 8g.

322323

Line No.(s)

311 02

Line No.(s)

YesNo

312314317 1

2

YesNo

318 1

2

YesNo

319 1

2

Yes – Assign CU No. 1 

in item 8g

No – Ask item 8e (4)

320 1

2

Yes – Ask item 8e (5)No – Assign CU No. 1 

in item 8g

321 1

2Assign to same CU in item 8g.

322323

Line No.(s)

01

llllll

llllll

llllll

llllll

llllll

llllll

Yes – Assign next a

CU No. in item 

No – Ask item 8e (4Yes – Ask item 8e (No – Assign next a

CU No. in item 

llllll

llllll

llllll

llllll

llllll

llllll

llllll

llllll

llllll

llllll

345 1

2

YesNo

346 X All347 348 349353 1

2

YesNo

Persons 354

lll

lll

lll

CONTRIB

PURCH

PURCHA SR

BUS_RENT BUS_EX PN

MEM_A WY

MEM_NU M

,

A WA Y

GUESTS

GUESTSQ
401

FORM CE-802 (1-1-98)© Section 2 – CONSUMER UNIT CHARACTERISTICS (FIELD REPRESENTATIVE – Ask items 1–7 at Week 1 placement.)

Ask if not apparent from observation.

1a. Are these living quarters presently used as student housing

by a college or university?

b. Are your living quarters owned or being bought by you (or any

members of your CU)?

c.

Probe:Are these quarters owned by regular ownership or as a condominiumor cooperative?In this survey, we consider a cooperative to be property which isowned by a corporation. Each shareholder is entitled to occupy anindividual unit. Is this what you mean? (FIELD REPRESENTATIVE: If the

respondent answers "No" to the probe, try to determine whether the

ownership is "regular" or "condominium" and mark the appropriate box.)

d. Are your living quarters rented for cash rent or occupied without

payment of cash rent?

Ask if "Yes" in item 1b.

2. Do you have a mortgage on this property?3a. Since the 1st of (Month, 3 months ago), what was your usual weekly

expense at the grocery store or supermarket?About how much of this amount was for nonfood items, such as paperproducts, detergents, home cleaning supplies, pet foods and alcoholicbeverages?Have you (or any member of your CU) purchased any food ornonalcoholic beverages from places other than grocery stores, suchas home delivery, specialty stores, bakeries, convenience stores, dairystores, vegetable stands, or farmers markets? Include any large

purchases made for freezing or canning.

What was your usual weekly expense at these places?

4a. Do you own an automobile, truck, or other vehicle?

Do not include any vehicle which is used entirely for business purposes.How many?Is this (are any of these) vehicle(s) used partially for business?Ask if "Yes" in item 4c.What percent of your total vehicle expense is counted as a businessexpense? Enter to nearest whole percent.

12

Yes – Go to item 3aNo

402 1

2

Yes – Go to item 1cNo – Go to item 1d

403 1

23

Regular ownershipCondominiumCooperative – Read probe and

then skip to item 2

404 1

2

Rented for cash

Go to item 2



Occupied withoutpayment of cash rent

Go to item 3a



405 1

2

YesNo

b.

406

0 None – Go to item 3c

$ .00

c.d.

407

0 None

408 1

2

YesNo – Go to item 4a

409410 1

2

YesNo – Go to item 5a

b.c.d.

411 Number412 1

2

YesNo – Go to item 5a

413 Percent

Ask only if preschool or school age 

5a. During the previous 30 days, ha

meals at school or in a prescho

b. If "Yes" – What are the names of 

purchasing meals at school in colu

6. What is your telephone number7. What is the best time of day to 

FIELD REPRESENTATIVE – Explain 

427428429430

PROCESSING USE ONLY

$ .00$ .00

.00

426

ST_HOUS

OWNED

TYPOWND

RENTED

MORT

GROCERYX

NONFOODX

OTHFOOD

OTHFOODX

OWN_VEH

VEHQ

VEH_BUS

BUSPCT
FORM CE-802 (1-1-98) 

© Section 3 – DIARY CHECK (FIELD REPRESENTATIVE

WEEK 1 PICKUP

Part 1 – FOOD AWAY FROM HOME

Did you (or members of your CU) have any expenses, which you did not enter in your Diary, for meals, snacks,nonalcoholic or alcoholic drinks purchased from fast food, delivery, concession stands, buffets, or cafeterias?

Yes No Don’t know

a

Line

No.

PROCESSING

USE

1 23

101102103111112113114

a

Line

No.

PROCESSING

USE

1 23 Yes No Don’t know

Purchased from full service restaurants where you (or members of your CU) paid for your meal after eating it?Now I am going to quickly go through a list of items to help you remember purchases you (or members of your CU) may have forgotten to enter in your Diary.

b de

List all meals, snacks, and

beverages purchased

Were alcoholicbeverages includedin total cost? If "Yes," How much?

Dollars Cents

c

Total cost

Include tax

and tip

Dollars Cents

Mark (X) one

Yes No

1 2

b d e

List all meals, snacks, and

beverages purchased

Were alcoholicbeverages includedin total cost? If "Yes," How much?

Dollars Cents

c

Total cost

Include tax

and tip

Dollars Cents

Mark (X) one

Yes No

1 21 21 2

Did you (or members of your CU) hanonalcoholic or alcoholic drinks pur

Yes 

a

Line

No.

PROCESSING

USE

1 2

101102103111112113114

a

Line

No.

PROCESSING

USE

1 2

Yes 

Purchased from full service restauran

LisLis

115116117118119

115116117118119

1 21 21 21 21 21 21 2

104105106107108109110

104105106107108109110

Now I am going to quickly go througyour CU) may have forgotten to ente

1 21 21 21 21 21 21 21 2

A NYFA ST

A NYFULL

LINENUM

A LC_HOL A LC_COST
FORM CE-802 (1-1-98)© Section 3 – DIARY CHECK (Continued)

WEEK 1 PICKUP

Part 1 – FOOD AWAY FROM HOME

Purchased from employer or school cafeterias?

Yes No Don’t know

a

Line

No.

PROCESSING

USE

1 23

128129130134135132133

a

Line

No.

PROCESSING

USE

Yes

No Don’t know

1 2 3

Did you (or members of your CU) have any expenses, which you did not enter in your Diary, for catered affairs?

a

Line

No.

PROCESSING

USE

Yes

No – Go to part 2 Don’t know – Go to part 2

1 23

For board or meal plan?

b c

Total cost

Include tax

and tip

Dollars Cents

b de

Were alcoholicbeverages includedin total cost?

If "Yes,"How much?

Dollars Cents

c

Total cost

Include tax

and tip

Dollars Cents

Mark (X) one

Yes No

1 2

b c

Total cost

Include tax

and tip

Dollars Cents

1 2

Yes 

a

Line

No.

PROCESSING

USE

1 2

128129130134135132133

a

Line

No.

PROCESSING

USE

Yes

1 2 

a

Line

No.

PROCESSING

USE

Yes

12 

List 

b

Lis

List 

b

Purchased from employer or school 

131 131

Did you (or members of your CU) havFor board or meal plan?

List all meals, snacks, and

beverages purchased

List all meals, snacks, and

beverages purchased

List all meals, snacks, and

beverages purchased

120121122123

a

Line

No.

PROCESSING

USE

1 23 Yes No Don’t know

Did you (or members of your CU) have any expenses, which you did not enter in your Diary, for meals,snacks, nonalcoholic or alcoholic drinks purchased from vending machines or mobile vendors?

b d e

List all meals, snacks, and

beverages purchased

Were alcoholicbeverages includedin total cost?

If "Yes,"How much?

Dollars Cents

c

Total cost

Include tax

and tip

Dollars Cents

Mark (X) one

Yes No

1 21 21 21 2

120121122123

a

Line

No.

PROCESSING

USE

1 2

Yes 

Lis

Did you (or members of your CU) hasnacks, nonalcoholic or alcoholic dr

A NYVEND

A NYCA FE

A NYBORD

A NYA FFR
FORM CE-802 (1-1-98)© Section 3 – DIARY CHECK (Continued)

WEEK 1 PICKUP

Part 2 – FOOD FOR HOME CONSUMPTION

Did you (or members of your CU) have any expenses which you did not enter in your Diary for food,nonalcoholic or alcoholic beverages, such as grocery items, purchased to be eaten at home?

Yes No – Go to part 3 Don’t know – Go to part 3

a bc d

Line

No.

PROCESSING

USE Describe item purchased

Is this item –

Mark (X) one

Fresh Frozen

Bottled

or

canned

Other

Total cost

Do not

include sales

tax

Dollars Cents

1 2 3

202203204205206207208209210211215216217218219220221212213214

Yes 

a 

Line

No.

PROCESSING

USE 

1 

Did you (or members of your CU) hnonalcoholic or alcoholic beverage

201 1234 222223224225226227228229230

1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 

202203204205206207208209210211215216217218219220221212213214201222223224225226227228229230

A NYFOOD

LINENUMPK G_TYPE
FORM CE-802 (1-1-98)© Section 3 – DIARY CHECK (Continued)

WEEK 1 PICKUP

Part 3 – FOOD AND BEVERAGES PURCHASED AS GIFTS

Did you (or members of your CU) have any expenses which you did not enter in your Diary for food,nonalcoholic or alcoholic beverages for someone outside your CU?

Yes No – Go to part 4 Don’t know – Go to part 4

a bc d

Line

No.

PROCESSING

USE Describe item purchased

Is this item –

Mark (X) one

Fresh Frozen

Bottled

or

canned

Other

Total cost

Do not

include sales

tax

Dollars Cents

1 2 3

301302303304305

1 2341 2341 2341 2341 234

Part 

Yes No 

a 

Line

No.

PROCESSING

USE 

1 2 

WEEK 1 PICKUP

Part 4 – CLOTHING, SHOES, AND JEWELRY

Did you (or members of your CU) have any expenses which you did not enter in your Diary for clothing,shoes, or jewelry?

Yes No – Go to part 5 Don’t know – Go to part 5

a b

Line

No.

PROCESSING

USE Describe item purchased

1 2 3

401402403404405

c d e

Total cost

Do not

include sales

tax

Dollars Cents Yes No

1 2

406407408

Was this boughtfor someoneoutside yourconsumer unit?

Mark (X) one

Enter code

For whom was thisitem purchased? 1 – Male 16 or over2 – Female 16 or over3 – Male 2 through 15 4 – Female 2 through 15 5 – Under 2 years

1 21 21 21 21 21 21 2

Yes No 

a 

Line

No.

PROCESSING

USE Desc

1 2 

1 21 2

1 234 306

409410

Did you (or members of your CU) hanonalcoholic or alcoholic beverages Did you (or members of your CU) hashoes, or jewelry?

301302303304305401402403404405406407408306409410

A NYFDGFT

A NYCLOTH

LINENUM LINENUM PK G_TYPE

A GE_SEX
FORM CE-802 (1-1-98)© Section 3 – DIARY CHECK (Continued)

WEEK 1 PICKUP

FIELD REPRESENTATIVE – GO TO SECTION 1, ITEMS 5b–d ON PAGE 2 AND 17a–b ON PAGE 3, AND LEAVE DIARY FOR WEEK 2.

Part 5 – ALL OTHER PURCHASES AND EXPENSES

Did you (or members of your CU) have any expenses which you did not enter in your Diary for tobacco, gasoline,or postage stamps?

Yes No

a b

Line

No.

PROCESSING

USE Describe item purchased

1 23

501502503504505

c d

Total cost

Do not include

sales tax

Dollars Cents Yes No

1 2

506507508

Was this boughtfor someoneoutside yourconsumer unit?

Mark (X) one

Don’t know

1 21 21 21 21 21 21 2

P

Yes No

a 

Line

No.

PROCESSING

USE 

1 2

Did you (or members of your CU) have any expenses for any other items which you may have forgotten to enterin your Diary?

Yes No – Go to Field Representative

instructions at bottom of page

a b

Line

No.

PROCESSING

USE Describe item purchased

1 2 3

510511512513514

c d

Total cost

Do not include

sales tax

Dollars Cents Yes No

1 2

515516517

Was this boughtfor someoneoutside yourconsumer unit?

Mark (X) one

Don’t know – 

1 21 21 21 21 21 21 2

Yes No 

a 

Line

No.

PROCESSING

USE 

1 2 

1 2 

1 2 

509518

Did you (or members of your CU) haor postage stamps?Did you (or members of your CU) hain your Diary?

Go to Field Representative

instructions at bottom of page

501502503504505506507508510511512513514515516517509518

A NYTGPS

A NYOTHER

LINENUM
Section 4 — WORK EXPERIENCE AND INCOME

Part A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00

$

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00

$

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00

$

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?

During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?

Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00

$

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

1

602603604607

609

610611613612614615616617618619620621622623

608

MEMBNO

PA GENUM

WK S_WRK D

HRSPERWK

OCCULIST

EMPLTYPE

INCORP

WHYNOWRK

HA VEWA GE

WA GEX

HA VEBSNS

BSNSX

BSNSLOSS

HA VEFA RM

FA RMX

FA RMLOSS

A NYSSINC

A NYRA IL

SS_RRX

MEDICA RE

SS_RRQ
FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU me

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.

Section 4 — WORK EXPERIENCE AND INCOME – ContinuedPart A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00

$

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00

$

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00

$

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00

$

12

YesNo

Number

8. Dur

receAny che

a.

Any cheGov

b.

Ask 

"Yes

How Supche

9.

Ask 

"YES

If 6a 

Whalast this 

10. Was 

. . .’If YE

FedStatSoc

Ask Are dedRail

a.

b.

11.

Ask 

12. Oth

empfor conplan 

13a. Dur

placsuc(IRA 

14. FIEL

GovPriv

c.

d.

e.

f.

g.

Ask How 

b.

Mar

the r

resp

DoeSecport

Is "YES" marked in items 7a and/or 7b?

04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

2

602603604607608

609

610611613612614615616617618619620621622623

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.
FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

Section 4 — WORK EXPERIENCE AND INCOME – ContinuedPart A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00

$

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00

$

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00

$

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00

$

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

3

602603604607608

609

610611613612614615616617618619620621622623
Section 4 — WORK EXPERIENCE AND INCOME – Continued

Part A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00 $

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00 $

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00 $

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?

During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?

Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00 $

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

4

602603604607608

609

610611613612614615616617618619620621622623
Section 4 — WORK EXPERIENCE AND INCOME – Continued

Part A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00

$

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00

$

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00

$

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?

During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?

Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00

$

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

5

602603604607608

609

610611613612614615616617618619620621622623
Section 4 — WORK EXPERIENCE AND INCOME – Continued

Part A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00 $

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00 $

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00 $

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?

During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?

Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00 $

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

6

602603604607608

609

610611613612614615616617618619620621622623
Section 4 — WORK EXPERIENCE AND INCOME – Continued

Part A

1. FIELD REPRESENTATIVE ITEM

Enter the first name and line

number of each CU member

14 years old and over.

Weeks

601

0 Did not work – 

Go to item 5

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask a separate page in Part A for each CU mem

2. In the last 12 months, how many weeks

did . . . work either full-time or part-time,not counting work around the house?Include paid vacation and paid sick leave.

3. In the weeks that . . . worked, how many

hours did . . . usually work per week?

4a.

Show Information Booklet, page 44

b. Was . . .

12

YesNo

.00 $

12

YesNo – Go to item 6b

PROCESSING

USE ONLY

NAMELINE NUMBER

a.

b.

Hours perweek

01 – Administrator, manager02 – Teacher03 – ProfessionalCODE1 –2 – A FEDERAL government employee?3 – A STATE government employee?4 – A LOCAL government employee?5 –6 –

CodeCode

Ask if code 5 and not a 

farm – Is the business 

incorporated?

Administrative support, technical, salesOperator, assembler, laborerPrecision production, craft, repairFarming, forestry, fishingArmed forces

5.

Ask if item 2 marked "Did not work" –CODE1 – Retired?2 – Taking care of home/family?3 – Going to school?4 – Ill, disabled, unable to work?5 – Unable to find work?6 – Doing something else? – SpecifyWhat was the main reason . . . didnot work during the past 12 months?Was . . .

Code

6. During the past 12 months, did . . .

receive any money in – Wages or salary? Include commissions,

tips, Armed Forces pay and allowances. 

What was the amount of incomereceived before any deductions?

a.

.00 $

12

YesNo – Go to item 6c

Income or loss from . . .’s ownnonfarm business, partnership, orprofessional practice?What was the amount of income orloss after expenses?

b.

1 Loss

c. Income or loss from . . .’s own farm?

What was the amount of income orloss after expenses? .00 $

12

YesNo – Go to item 7

1 Loss12

YesNo

7. During the past 12 months, did . . .

receive from the U.S. Governmentany money – 

a. From Social Security checks?

From Railroad Retirement checks?FIELD REPRESENTATIVE CHECK ITEMWhat was the amount of the lastSocial Security or RailroadRetirement payment received?

During the past 12 months, howmany Social Security or RailroadRetirement payments did . . . receive?

Is this amount AFTER the deductionfor a Medicare premium?

e.

d.

c.

b.

f.

12

YesNo

12

Yes – Go to item 7d No – Go to item 8a

.00 $

12

YesNo

Number

8. Durin

receivAny Scheck

a.

Any ScheckGover

b.

Ask if 

"Yes" 

How mSupplcheck

9.

Ask ite

"YES"

If 6a is 

What last pthis c

10. Was t

. . .’s If YES 

FederState Socia

Ask if Are SdeducRailro

a.

b.

11.

Ask if 

12. Other 

emplofor ducontrplan t

13a. Durin

place such a(IRA & 

14. FIELD 

GoverPrivat

c.

d.

e.

f.

g.

Ask if How m

b.

Mark (

the res

respon

Does Securportio

Is "YES" marked in items 7a and/or 7b?

The job in which . . . received the mostearnings during the past 12 monthsfits best in the following category:Enter one code.04 –Manager, professional05 – Sales, retail06 – Sales, business goods and services07 – Technician

Administrative support, including clerical

Service08 – Protective service09 – Private household service10 – Other service11 –12 – Transportation operator13 – Handler, helper, laborer

Machine operator, assembler, inspector

14 –15 – Construction, mining

Mechanic, repairer, precision production

16 – Farming17 – Forestry, fishing, groundskeeping18 – Armed forces

An employee of a PRIVATEcompany, business, or individualworking for wages or salary?

Self-employed in OWN business,professional practice, or farm?Working WITHOUT PAY in familybusiness or farm?

FORM CE-802 (1-1-98)

605

7

602603604607608

609

610611613612614615616617618619620621622623
Section 4 — WORK EXPERIENCE AND INCOME – Continued

Part B – Ask for entire CU as a group

1. During the past 12 months, did you (or any members of your CU) receive income from any of the following – 701

FIELD REPRESENTATIVE – Complete at Week 2 pickup. Ask these items for the entire CU as a group.

Income from worker’s compensation or veteran’s benefits including education benefits, but excluding military retirement?Income from public assistance or welfare including money received from job training grants such as Jobs Corps?

12

YesNo – Go to item 1b

.00 $

.00 $

12

YesNo

12

YesNo – Go to item 2b

2. During the past 12 months, did you (or

any members of your CU) receive any –Lump sum payments from estates, trusts,royalties, alimony, prizes or games ofchance, or from persons outside of the CU?

a.

Money from the sale of householdfurnishings, equipment, clothing, jewelry,pets or other belongings, excluding thesale of vehicles or property?

c.

b.

.00 $

3. During the past 12 months, did you (or any

members of your CU) receive any refundsfrom the following –Federal income tax?State and local income tax?Overpayment on Social Security?Insurance policies?

a.

b.

Property taxes?Other sources, including any othertaxes?

c.

d.

e.

f.

FORM CE-802 (1-1-98)

702703705

725

724726727

a. Income from unemployment compensation?

If YES – What was the total amount

received by ALL CU members?

b.

If YES – What was the total amount

received by ALL CU members?

c.

12

YesNo – Go to item 1c

.00 $ 704

12

YesNo – Go to item 1d

.00 $ If YES – What was the total amount received by ALL CU members? 706

d. Income from interest on savings accounts 

or bonds?If YES – What was the total amount

received by ALL CU members?

707 1

2

YesNo – Go to item 1e

.00 $ 708

e. Regular income from dividends, royalties,

estates, or trusts?If YES – What was the total amount

received by ALL CU members?

709 1

2

YesNo – Go to item 1f

.00 $ 710

f. Income from pensions or annuities from

private companies, military, or Government,IRA, or Keogh?If YES – What was the total amount

received by ALL CU members?

711 1

2

YesNo – Go to item 1g

.00 $ 712

g. Net income or loss from any type of rental

of rooms or living units?

713 1

2

YesNo – Go to item 1h

If YES –(1) How much net income or loss was

 received from roomers or boarders?

(2) How much net income or loss was

 received from payments from other rental units?

.00 $ 714

715 0

1

NoneLoss

.00 $ 716

717 0

1

NoneLoss

i. Income from regular contributions from – 723 1

2

Yes

(1) Alimony? No(2) Other sources such as from persons

 outside the CU?

If YES – for item i(1) or i(2) –Altogether what was the total amountreceived by ALL CU members?If YES – What was the total amount

received by ALL CU members?

If YES – What was the total amount

received by ALL CU members?

12

YesNo – Go to item 2c

.00 $

728729

Other money income, including moneyreceived from cash scholarships andfellowships, stipends not based onworking, or from the care of fosterchildren?If YES – What was the total amount

received by ALL CU members?

12

YesNo – Go to item 3

.00 $

730731

If YES – What was the total amount

received by ALL CU members?

4. D

oFe

a.

If 

m

Sw

b.c. P

O

S

d.

.00 $ 722

h. Income from child support? 718 1

2

YesNo – Go to item 1i

If YES –(1) Did you receive a one time lump 

 sum payment for child support?

719 1

2

Yes

If YES – What was the total amount received

by ALL CU members in last 12 months? .00 720 $

(2) Did you receive any child support

 payments in other than a lump sum  amount?

721 1

2

Yes

If YES – What was the total amount received

by ALL CU members in last 12 months?

No – Go to

 item 1h(2)

No – Go to

 item 1i

12

YesNo

.00 $

732733

12

YesNo

.00 $

734735

12

YesNo

.00 $

736737

12

YesNo

.00 $

738739

12

YesNo

.00 $

740741742 Yes – Specify

5. D

yuaIf 

o

6a. D

rAm

b.

HsIf 

c.

7a. D

rpWs

b.

8a. D

C

c. W

Ir

b. 

9a. I

r

b. W

r

s

p

c. W

F

i

.00 743 $2 No

1

COMP

UNEMPX

WORK COMP

WRK RSX

PA WELFA R

WELFRX

INT

INTX

DIV

DIVX

PENSION

PENSIONX

RENTA L

ROOMX

ROOMLOSS

OTHRNTX

OTHLOSS

CHDSUP

CHDLMP

CHDLMPX

CHDSPOTH

CHDOTHX

A LIMSUP

OTHCONT

A LIOTHX

LUMP 

SA LE

SA LEX

OTHIN

OTHINX

FEDREF

FEDREFX

STA TREF

SSREF

SSREFX

LUMPX

STA TREFX

INSREF

INSREFX

PTA X REF

PTA X REFX

OTHREF

OTHREFX
FORM CE-802 (1-1-98)

NOTES
Table X — Determing if an Additional Living Quarters Qualifies as an EXTRA Unit

Start Here

FORM CE-802 (1-1-98) 

UNIT SEGMENTS 

(1) (2) (3) (4) (5) (6) 

Check the listingsheet. Is the addressof the additional livingquarter already listed?

Yes – Stop Table X.No – Go to column (2),

(4), (5) or (6)

depending on

segment type.

AREA SEGMENTS PERMIT SEGMENTS

Single Unit Multi-Unit

Are the additionalliving quarters withinthe area segmentboundaries?

Are the additionalliving quarters in agroup quarters?

Are the additionalliving quarters withinthe same structure andwithin the same space

(See Footnote 1)occupied by theoriginal sample unit?

Are the additionalliving quarters withinthe basic address(house number andstreet name) of theoriginal sample unit?

Are the additionalliving quarters withinthe same space (See

Footnote 1) occupied by

the original sampleunit?

and

Are the additinalliving quarters theresult of a splitapartment?

Yes – Go to column (3).No – Stop Table X; do

not interview.

Yes – Stop Table X; do 

not interview.

No – Go to column (7).

Yes – Go to column (7).No – Stop Table X; do

not interview.

Yes – Go to column (7).No – Stop Table X; do

not interview.

Yes to both questions –Go to column (7).No to either question –Stop Table X; do not

interview.

FOOTNOTES:

1 – Occupation of the "same space" occurs if a housing unit has been split into two or more separate housing units.2 – If you determine that you have found an EXTRA unit at a single unit address in a UNIT segment (yes in column (5)), you must prepare an INTER-COMM and fill out a BLANK 

NOTES
17. RECORD OF TRAVEL TIME

FORM CE-802 (1-1-98)

Record travel time and enter reason code for personal contact from list of personal contact codes to the right.

Trip Time Reason OFFICE USE

ONLY

18. RECORD OF INTERVIEW AND OFFICE ACTIVITY TIME

(a) (b) (c)

Trip Time Reason OFFICE USE

(a) (b) (c) ONLY

Trip Time Reason OFFICE U

(a) (b) (c) ONLY

1234

5678

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832 833834 835836 837838 839

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840 841842 843844 845846 847

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848 849850 851852 853854 855

9

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