Part C —- INCOME — Ask ot Week 2 Pick-up

1 — An employee of a PRIVATE company, business, or Individual working for wages or salary?
2 ~ A Government employee? (Federal, Store, focal)
3 — Self-employed In OWN business, professional practice, or farm?
4 — Working WITHOUT PAY In family business or farm?

If code 3 and net a form, ask
1s the business Incorporated?

ta) Yes = 2[jno

- If code 3 and nor o farm, ask
Is the business incorporated?

1C}Yes = 2CNo

1 code 3 und not a form, ask
Is the business incorporated?

08) « |_j ves 2|7 NO

~ 14019 ~ 07+ ~ 14035 ¥ ~ 14043 ¥ ~ 14050 ¥
Line No, Line No. Line No. Line No. Line No.
@ Ask items 1-4 for each person 14 years old or over in this CU _ ine No
1. How many weeks during the past 12 months did ... work, either full-time or part-time, Weeks oR —__Weeks oR Weeks OR Weeks OR Weeks OR
not counting work around the house? 0 [] Did not work — © ([] Did not work — © |_| Did not work ~ 0 ([] Did not work — 0 [| Did not work —
SKIP 103 SKIP to 3 SKIP to 3 SKIP 103 SKIP to 3
2a. In the job in which ... received the most earnings during the past 12 months, for whom did he work? _
b. What kind of business or industry was it? | . J
c. What kind of work dld he do? nal S09
d. Was...
code Code Code code code

If code 3 ond not 0 farm, ask ~
Is the business incorporated?

UCTYES — 2f7 NO

Hf code 3 ond not a form, osk —
Is the business Incorporated?

0) ives = 2 jNo

3. Is... retired?

© If “Did not work’! during the post 12 months and over 50 yeors old, osk —

\Edves 2(-1No ana

@ i(rives 2CNO sina

1, YES 2[[]NO 3[]NA

1[QYES 20) NO 3]NA

tC] Yes 2—]NO az JNA

b. NET income from own business or professional practice?

4, During the past 12 months, how much did. . . earn in —
a. Wages or salary before deductions? (Include commissions, lips, Armed Forces poy and allowances.)

.. 1@9

$ ——__..00 OR 0[ 7] Nor
$ ———.00 OR 0[7 Nor

ne § —___.00 O80 None
ne $ ———-.00 OR of—] None

$_____.00 OR o| , None
G09) §____.00 oR oj None

$——..00 OR 0f7j None
$————.00 OR o[[] None

$——_. .00 oR o[_] None
$—— .00 OR 07] None
@9s__ OR 0,_] None

¢. NET income from own fat? cee e eee cc ce v cece eeeeees $ 00 of o( "None §_—___.00 of o[-j None $..__.00 OR 0 [7] None $00 oR 0 None
~15016 > + | PartD-DIARY CHECK —Ask at Week 2 Pick-up ~150244
@ Ask item 5 for the entire CU WES - INTERVIEWER — Review the completed diary for the items listed in col.o. If expenditures of $1.00 or more are reported, mark the box in col. o.
How much After reviewing the entire diory, ask the questions in col. b for each box that is NOT marked in col. 0.
5. During the past 12 months did any members of this CU receive any money from - YES NO altogether? > If all boxes are morked, complete Part A, items 15d and 15e, then continue with Part C.
Mark the box if @ Ask b, and ¢ if box ii i
: , . A questions 0, b, and ¢ if box in col. a is NOT marked.
a, Social Security or Railroad Retirement checks from the U.S. Govemment? 1 2 $ —___..00 expenditures of 31.00 We have found that certaln types of expenses are often forgotten, | would like to ask a few questions concerning these Items,
—_ (a) (b)
YES NO lL ’. Does anyone in the family eat out — lunches, dinners, snacks, etc. —

b. Estates, trusts, ordividends?, 2. ee 1m ep 00 even occasionally? — EV YES_[{]NO = SKIP 0 nex item
Interest on savings accounts or bonds? * ow s —_ (Meals eaten out | b. Did anyone in the family eat out at all during the past week? [YES TINO - SKIP to next item —
Net rental income? 2.0.2 ee m :

sO sO c. How much was spent for meals eaten out during this past week? § 00
2 a, Does anyone In the family smoke — cigarettes, cigars, ;
c. Welfare payments or other public assistance (aid to families with Yes NO pipes — even occasionally? CTYES [7] NO — SKIP 10 next item
dependent children, old age assistance, or aid to the blind or totally disabled)? ‘oO 2f) $_ 0 b. Did anyone in the family buy any cigarettes, cigars, or tobacco
1 Tobacco during this past week? LO YES (NO = SKIP 10 nex item
YES NO
c. How much was spent during this past week? $ 00
d. Unemployment compensation? ..........2........-..00.. tL) 24 _
¥ 3. ‘a. Does anyone In the family buy alcoholic beverages — beer, oo
Workmen’s compensation? 2... eee af] 4 $ 00 wine, liquor, etc, — for HOME USE, even occasionally? [YES [_] NO — SKIP to next Hem
Government employee pensions? 0... 2... oe eee eee eee eee sf «sO o ecatoees for [Be Did anyone buy any alcoholle beverages for HOME USE during this past week? LIYES [NO ~ SKIP 10 next item
Veteran's payments? .. 2... ee 7 el) HOME USE
i c. How much was spent during this past week? s nal
YES NO = 7
a. Does anyone In the family buy alcoholic drinks at a bar, café, etc.

e. Private pensions or annuities? 12 4 even occasionally? , [YES [[)NO — Go to Part A, item 15d
Alimony? * — (Alcoholic drinks drinks duri 2 - _ stem}

2 eee amo @ 5 40 purchased ata | D!4 anyone buy any ateoholie drinks during this past week? LL] YES (NO ~ Go to Part A, item 15d
Regular contributions trom persons nat living in this household? 2.2.2... sf) st) bat, cate, lc. | «ow much was spent during this past week? 5 00
Anything else?. 2... 02. ee 7) 8

Continue with Part A, items 15d and 15e AND Part C.

FORM CE-106 (4-11-72)

USCOMM-DE


~ 01016 >

0.M.6. No, 41-S72032; Approval Expires December 31, 1974

Form CE-106 1. Sample |2. Expected |3. Control aumber 4. Household} 5. Consumer) 6. PROCESSING USE ONLY
(411972) U.S. DEPARTMENT OF COMMERCE week units . ‘ . . number Unit No.
SOCIAL AND ECONOMIC STATISTICS ADMINISTRATION PSU | Sample ' Serial 'Ck. Dig. b. oe 4.
BUREAU OF THE CENSUS i ' |
ACTING AS COLLECTING AGENT FOR 1 H 1 72
U.S, DEPARTMENT OF LABOR 4 1 1
BUREAU OF LABOR STATISTICS 7. SAMPLE 2. House number and street
ADDRESS
b. Apt. No. of other unit designation
©. City State ZIP code
, 8. MAILING 2. House number and street
QUESTIONNA:RE ADDRESS
~ cen {J Same as b, Apt. No. or other unit designation
~ sample
a address
“1972-1973 DIARY SURVEY (item 7) Tercity State ZIP code
nail
11023 ¥ 9. SPECIAL a. Name d. Code c. Expected units
NOTICE — Al! information which would permit identification of the individual will be held in strict confidence, will be used only by PLACE
persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes.
10. Interviewer’s name ; Code
t 13, FINAL INTERVIEW STATUS — Enter the appropriate code (1-17) for both placement and pick-up for each week. NOTES
! If code 1, also enter the month ond doy.
Cade
Ma, RECORD OF CALLS Date Te 1 - Diary placed or completed
-_ _ WEEK 1 WEEK 2
p.m, p.m. NONINTERVIEW CODES
2.m. a.m, DIARY PLACEMENT OIARY PLACEMENT
p.m, p.m. Type A
9 a 2 - Unable to contact
a.m. am, 3 ~— Temporarily absent ducing entire reference week —-. — Code Code
p.m. pm.
a.m, am.] 4 — Refused
p.m, p.m, _ _ an
aa — 5 - Other - Specify in Notes Mo./Day Mo./Day
p.m. p.m,
aa. am, Type B
pm pin. 6 — Vacant
1lb. DIARY DATES 7 — Occupied by persons with URE DIARY PICK-UP DIARY PICK-UP
WEEK 1 , WEEK2 __ 7 8 — Under construction, not ready
=," 1 Poy Ye. = 1 Py S| 9 Other —specify-in-Notes:—
14 14 spe € coue cose
T ~ T
° I { ° H ' 10 — Demolished a
2 SUPERVISOR'S Tse Lt 11 - House or trailer moved Mo./Day Mo./Day
- 12- Converted to permanent nonresidence
Initials Date 13 ~ Mereed
a. Recheck ~ mere Hf code 1, mork uppropriate box If code 1, mark appropriote box
- 14 ~ Condemned 07) Completed b: deat Completed b: dent
. 1 ol Ss)
b. Observation 15 - Located an military base (post) L' Completed by responden ‘LI Completed by respondent
16 - CU no longer at sample address 2|_' Partial recall 2 [7 Partial recall
17 — Other - Specify in Notes 3| >] Total recall 3 (CJ Total recall



~ 12013 >

Part A HOUSEHOLD CHARACTERISTICS

@ ASK OF ALL UNITS

@ (ASK IF MARKED

3, LIVING QUARTERS — ASK IF NOT APPARENT 8Y OBSERVATION

la. Are these living quarters — @ Ask if code 1 | c. Are these living quarters d. What percent |e. When did | 2a. Does this piace have 10 acres or more? a. Do you have complete jb. Do you have direct c. Housing unit H d. Other unit
f or 2 in item lo used partly for business of the you move kitchen facilities? 1 access from the 1 C] House, apt., flat 1
1] Owned of being bought By | ou have a | oF Peed to others? expenses is | to this VIVES ~ Ask 260) ENO, mock “None. 1 outside or through oP en peri
scoperative ty contoninive)? . morgage on counted as address? 20] NO = Ask 262) «mark “None."” | a common hall? 2{C] HU in Special Place boarding house
v ; S a business is |
2(C)A cooperative or condominium this property? (No - Skip to Te expense? b. During the past 12 months, did sales of " ves Pee they tor is ! 21] Yeates nat in {6 Tentor trailer site
ed of being bought b . During the past 12 months, did sales o \ i i e H -
Someone In ins al? Y ves 2 (] Part business crops, livestock, and ather farm products exclusive use? ! 4._} Yes, direct 4 (CHU not specities , 7 im piners rot HU
2 ; —___. ‘ _
32] Rented for cath rent? C) 3] Rented ® others Month from this place amount to 1 [SJexctusive use! access above = Describe y | 7;
4[_] Occupied without payment 2[)No su Lo etl % (1) $50 or more? 1 (] YES 2 NO] 2” Shaed i 5, | No, through H
. of cash rent? others Year (2) $250 or more? 37] YES aL] NO 2 None 1 another unit __!
~ 82 024 > HOUSEHOLD RECORD ] ~32 037 > CONSUMER UNIT RECORD CU No.
4, 5. 6 NAME Lost nome first 7. RELATIONSHIP 8. HOUSEHOLD 9. BIRTH 10. AGE lL. ea 12. SEX 13. RACE 14. ALF. Hf more than one CU, transcribe CU No. from
7 . MEMBER DATE TATUS MEMBER the first questionnaire for this household,
> . a What is the name of the head of this household? k t whit 17. LINE 18. FOR ALL ADDITIONS AND
é . : oe of
= Ss 2 as What is . . ."s relationshia to Is this. .."s | What was the | Enter oge | !S-. now - Male ~White Ask if male : .
S12 ]ss What are the names of all other persons living the head of the household? usual place | month and year | ct rime | 1 Married? 2-Black or | ove" M6veers NUMBER DELETIONS TO THIS CU
2 |= Sf] oF staying here: of residence? | of ...'s birth? | of first 2-Widowed? 2-Female
= Zw L “ bh ty live h 4 o1!| Example: Head, wife, son interview | 3 . Negro ls now © Transcribe In the appropriate column enter the
z ist olf persons who usually live here and o , Wife, son, —Divorced? nana ji
= o Jo? persons who are temporarily absent. Be sure daughter-in-law, uncle, Mork YES if | Example: 4-Separated ? 3-Other — inthe Armed ff — ins pembers dere the choose oeseree fer eee
8 =]: to include infants under } year of age. lodger, lodger’s wife no usual 01-40, 5Ne ‘ Specify | Forces? 42 one co Pe :
cs) at { Never is
s 2/2y Brow o heavy line under nome of lost person residence 12-05 married? Enter in Notes Zz 3a from item 5. Additions Deletions
- oO 1te . Code ves TNO wo. | yr. Enter code code Enter code | YES} NO J 2> mo. | pay! yr. | Mo. | DAY| YR.
. r t T 12 i] i ’ r r
1 i) 1
1 —_ I
T 7 q Tz T T T
1 / ‘ ' 1 1
2 1 H 1 (i) ( 1 1 1
1 i 1 12 H Hl H 1
: _| 4. —_ _
1 1 1 12 1 ( '
1
‘ a a) a a
ar a ot
§ 1 i Hl 1 1 1 1
1 i ul 12 ( ' 1 i)
é i i _
j H A t2 , Hl Hl
t
7 _ pot
T 1 i]
‘ ' 2 1 1 , i
8 I ! 1 \ \ ' '
i ! i 12 ( Hl 1 i
'
: | | _
1 1 A 12 f U U
i]
1 | i it
@ ASK AT WEEK ) PLACEMENT @ ASK AT WEEK 2 PLACEMENT @ ASK AT WEEK } AND
WEEK 2 PICK-UP ~ 12047 >
15a. I have listed... (read names from item 6). Have | missed — Yes | NO | 15b. {have listed ses (read ceatid from item Sh 1 | coves 15c. is anyone else living oi coves . WEEK | WEEK 2
. | re all of these persons st! ving or stayin; re? stayin re now, includin, ~
“Mattia a (OO a | ve | ania Lm |S Recaietorrmecten | ve | Ons
~ Any lodgers, boarders, or persons in your employ who live tere? |] 1 1 17. NO — Which persons have left the household? (during the dlary relerence period)? ... . . C)No (No
. - - For each person who has left the house- :
— Anyone who usually lives here but is temporarily absent at present - ' . : For each odded person, complete if YES ~ Which persons?
traveling, at school, or inahospital?, Qo 1 a Peers ics cmough nem 6 ond items 6-8. If YES in item 8, fill Enrer line numbers... 00.
* . items 9-14. letermine lo. + —
— Anyone else stayinghere?, | eee o:10a MO. | YR. from item 16a and fill item 4 on Ise. Did anyone else, such as visitors stay _
H If the entire household has moved, osk: ' the origine! questionnaire and here avernight for one day or more fast {"] YES (7 Yes
FILL ITEMS 6-8 FOR EACH PERSON ADDED. When did the ... family move? \ items 17 She dppeorte eu week (during the diary reference period)? no Cno’
“ 7 - Prepore a new questionnaire if
JF “YES IN ITEM 8, FILL ITEMS 9-14 FOR THE PERSON the unitis naw occupied. Raise i YES — How many such persons?
‘na i sue with i the househald number (item 4 ~ Y Such. persons ?
Afier completing item 150, continue with item 16 below. oe peresreld pes Enter the number of persons...



16a. INTERVIEWER CHECK ITEM FOR
ASSIGNING CU NO.

@ Enter ‘'J'" in item 4 on the fines for heod
of household, wife, never married children,
and ony other person listed who is
considered part of their fomily.

@ For all other individuals or closely
related groups ask items 16b-d, as
opplicable. Fill 9 separate line for each.

For separate CU's assign numbers in
sequence, e.g.
in the household.

@ NOTE:

“2"" for the second CU

NOTES

If 6 or fess CU's prepare o seporate
questionnaire for each CU ofter
completing the questionnaire for
CU No. 1. Enter in item 6 of the

additional questionnalre(s) the
names of ofl persons in the CU,
then fill item 17. If more than 6
CU's STOP the interview ond coll
the area office for instructions.

ASK FOR EACH INDIVIDUAL OR GROUP OF RELATED PERSONS @ ASK AT END OF PART A ON
NOT IDENTIFIED AS PART OF CU NO. “I” THE FIRST CE-106 PREPARED
financially independent |{6c. What items does he pay for | 16d. Who pays for the remainder? .
io] does ... pay for food himself? 1 pwo or more If more thon one CU in the
wi shelter, and clothing with listed items morked, assign ese One, OS he
= his own money? separate CU No. Otherwise, 19a. Does more than one person in this
ask item 16d, household regularly contribute to
YES — Assign separote CU . Other CU in HH — Enter CU No. in item 4. the expense af items such as food,
ao No. in item 4. CT Food (J Clothing Oo cleaning supplies, or paper products?
; ~ | Person not In HH — Specify in Notes and
(NO — Ask item 16c. C1 Shelter 1] None O assign separate CU No. in item 4. o
YES —Askb
YES — Assign seporote CU . _ ,
rs) Assign sepore [J Food LJ Clothing [7] Other CU in HH — Enter CU No. in item 4. [INO - SKIP v0 Pon 8
; Persons nat in HH — Specify in Notes ond
0 NO = Ask item j6c. (Shelter — (None OC Fesen separate CU No. in item 4.
b. Does one person usually make
71 Yes ~ Assign agperote cu CC Food (J Clothing [1] Other CU in HH - Enter CU No. in item 4. the purchases?
° . Person not in HH — Specify in Notes and Yes - Who?
(NO ~ Ask item 16e. [Shelter [7 None Ol assign separate CU No. in item 4 ES ne
Yes - Assign separate CU | Food L} Clothing (CJ Other Cu in HH — Enter CU No. in item 4, (no
. Person not in HH — Specify in Notes and NOTE: If YES, ask the person wh
[INO -Ask item 16c. 7 Shelter ([] Nona co assign separate CU No. in item 4. usvolly makes the purchases
to record the expenses for
© After assigning CU Nos. in item 4 for all listed persons, go to item 17 above. @ the shared items.

~13029 ¥ Port B- CONSUMER UNIT CHARACTERISTICS — Ask ot Week | Placement
@ ASK ITEMS 1 AND 2 FOR THE CU @ ASK ITEMS 3 AND 4 FOR
1a. About how often do you (CU) shop TJ Week HEAD OF CU ONLY E13) of tNever attended SKIP 10 4
al the grocery store? [7] Month Times Per 3a. What is the highest grade (year) of Elementary
— reeular school.» (head) has 203040 sOc6«O70ef
. attended?
b. During the past 3 months, what has been ever
the usual amount of your ‘purchases at CT Week High
the grocery store? $ -00 per sO roe
(Include purchases made with Food Stamps.) ] Month College
c. About how much of this amount was for ‘ eCeOisCe et
food and nonalcoholic beverages? $ 00
b. Did ... complete that grade (year)? €) yO yes 2([)NO
d. About how much of this amount was zi
for tobacco? $ 00 of JNone — | 4a, Has... ever completed a vocational
training program? (in high school; as an €3 1 Yes
About h fof thi ' apprentice; in business, nursing, trade,
e. About how much of this amount was technical, or Armed Forces school.) “| NO —SKIP 105
for alcoholic beverages? $ 00 oC} None ' 2{-] o
2a. Do you (CU) own an automobile, truck, or 1([) YES B. What was the main field of training?
other vehicle? Oo not include any vehicle 1 — Business & office work
which is used entirely forbusiness purposes. 2[[) NO - SKIP 103 2 — Nursing, other health fields =
3 — Trade or craft
4 ~ Engineering or science Code
b. How many? Number 5 ~ Agriculture or home economics
6 — Other ~ Specity %
c. Is this (are any of these) vehigle(s) 1) Yes
used partially for business? 2()NO- SKIP 103 =
PROCESSING USE ONLY € D
© 1f more than ane vehicle in 2b Area code { Number
d. How many? @) Number 5. What Is your telephone number? t
@ If partly for business fi
e. What percent of your total vehicle expanse 6 best time of day to am.
is counted as a business expense? (@P) Percent it? pm.

FORM CE-106 (4-11-72)