Port C —- INCOME —- Ask at Week 2 Pick-up
~ 14019 ¥ ~14027 ¥ ~ 14035¥ ~ 14043 ¥ ~ 14050 +

@ Ask items 1~4 for each person 14 years ald or over im this CU Line No. Line No, E01) Line No. @) Line No.

1. How many weeks during the past 12 months did . . . work, either full-time or part-time, 03) Weeks «OR Weeks or Weeks OR Weeks or

not counting work around the house? ©| [Did not work — SKIP to 3 ] Did not work ~ SKIP 103 ~] Did not work ~ SKIP to 3 9 [7] Did not work ~ SKIP 103

[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? _ : Go}) (G03) | 7 7
c. What kind of work did he do? Gos God | _ : [
d. Was...
1 — An employee of a PRIVATE company, business, or individual working for wages or salary? a) —— Code a3) —— Cote (G05) —___. Code Code Code
2 — A Government employee? (Federal, Store, loco!) If code 3 and nor a farm, ask = Hf code 3 and not o form ask — If code 3 end nor 0 form, osk — If code 3 end not a form, ork = If code 3 ond not a form, ask —
3 — Sell-employed in OWN business, professional practice, or farm? Is the business incorporated? Is the business incorporated? Is the business incarporated? Is the business incorporated? Is the business Incorporated?
4.— Working WITHOUT PAY in family business or farm? Gos) secyves | 2 ]No oe) s|_hyes ‘(yes = 2fNo ‘C)yves = 2) No 1Oves = 21 No
© Jf “Did not work’ during the past 12 mnths ond over 50 yeors ald, osk — - a -
B. Is... retired? 03) 1 | YES 2([]NO 3 oz)» (YES 2L Jno 3 Gor) 17 y YES 227]NO 3 [~)NA s{'¥es 2]NO [7] NA +LJY¥€s 2(CNO 3[7]NA
4. During the past 12 months, how much did. . . earn in -
a. Wages or salary before deductions? Include commissions, ips, Armed Forces pay ond allowances.) Goa) $_.._ 00 OR of_| None § OC OR 0! _: None S__.00 Of o[ None [Gos) $____.00 of 0 |_| None $_—__.00 OR 0 |_| None
b. NET income from own business or pratessianal practice? «2.20... 200. cece cece ee eeee vse. = | G03) 8.0 oR 0 [7 None Ga) § .00 OR 0 [7] None $___..00 oR of |None |Gog) S—._.00 oR 0} None Gos) $___.00 oR 9 [7 None
Ci toss [1 Less (CJ Less 1 Loss Coss
€. NET income from own farm? ... 000s. eee eee eee eee Lette eee e cette eee eeene G9 s 00 on 0 E19) 5 00 OR oj None $ 00 OR 9|_| None 5 U0 OR of _jNone $ 00 OR o|_| None
LJ boss (7) Loss [J] Loss (CT) Loss Co) Loss
Oltice use only Oo @) i eam @n @) 4 eNom ©) 54
v H
i Part D — DIARY CHECK — Ask ot Week 2 Pick-up . ~ 190244
© Ask item 5 for the entire CU YES - INTERVIEWER ~ Review the completed drury fur the tems listed in col.o. If expenditures of 5).00 or more ore reported, mork the box in col. 0.
; How much After reviewing the entire diary, ask the questions im col. b for each box that is NOT marked in col, a.
5. During the past 12 manths did any members of this CU receive any money from - YES NO altogether? > If alf boxes are marked, complete Part A, items 15d and I5e, then continue with Part C,
: : ; ' Mark the box if @ Ask i b, and ¢ if box in col NOT mark:
/ > ’ Ask questions o, b, ond ¢ if box in col. 0 is marked.
a. Social Security or Raitroad Retirement checks from the U.S. Govesnment? 00 epetitues ASD We have found that certain types of expenses are often forgotten. { would like to ask a few questions concerning these Items.
- _ (aj, (b)
L a, Does anyone in the family eat out — lunches, dinners, snacks, etc. —
b. Estates, trusts, or dividends? x even occasionally? _ [IL YES 7 ]NO ~ SKIP 10 next item
Interest on savings accounts or bonds? ° {[} Meals eaten ou: | b. Did anyone in the family eat out at all ducing the past week? (LI YES [jNO — SKIP to next item
Net rental income? .... 22... .
¢. How much was spent for meals eaten oul during this past week? $ 00
. . oo . a. Does anyone In the family smoke — cigarettes, clgars, 7 ;
c. Welfare payments or ather public assistance (aid to families with 2 pipes ~ even occasionally? [XV YES ["] NO ~ SKIP fo next item
dependent children, old age assistance, or aid to the blind or totally disabled)? Cn Tobacco b. Did anyone in the family buy any cigarettes, cigars, or tobacco rqves Gno-s
- a f - during this past week? Ye NO = SKIP to next item
~ YT a a _- ~ ——
; c. How much was spent during this past week? $C
d. Unemployment compensation? see eee
, . 3. a. Does anyone In the family buy alcoholic beverages — beer,
Workmen's compensation? . 0 wine, liquor, etc. ~ for HOME USE, even occasionally? CA YES (JNO ~ SKIP to next item
Government employee pensions? Ll bon for |B Dl anyone buy any alcahotic beverages for HOME. USE during this past wook? [AYES [[]NO = SKIP to next item
VEL: —.
Veteran's payments? HOME USE
- -4 c. How much was spent during this past week? § 00
4. a. Does anyone In the family buy alcoholic drinks at a bar, café, etc., _
e. Private pensions or annuities? . even occasionally? CO YES [7]NO - Goto Part A, tem 18d
Alimony? 2.2... ee i M toed ate b. Did anyone buy any aleohoilc drinks during this past week? TTYES [NO - Go 10 Part A, item 15d
e| ibuti iving in thi ? . é, etc. ~
Regular contributions from persons nat living in this household? bar, café, etc. c. How much was spent during this past week? 5 00
i 2
Anything else? Continue with Port A, items 1Sd ond }5e AND Part C.

UscomMe
(ORM CE-106 (3-20-73) Grn ae SCOMM-DE


~ 01 016 >

0.¢M.B. No. 41-S72032; Approvai Expires December 3), 1974

rorm CE-106

229-781

| ~11 023 +

U.S, DEPARTMENT OF COMMERCE
SOCIAL ANU ECONOMIC STATISTICS ADMINISTRATION
BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF LABOR
BUREAU OF LABOR STATISTICS

HOUSEHOLD
CHARACTERISTICS
QUESTIONNAIRE

1973-1974 DIARY SURVEY

NOTICE — All Information which would pernut identification of the individual will be held in strict confidence, will be used onty by
persons engaged in and for the purposes of the survey, and will not be disclosed or released fo others for any purposes.

1. Sample |2. Expected |3. Contro! number 4. Household] 5. Consume: | 6. PROCESSING USE ONLY
week units . . . number Urti No. -
PSU i Sample 1 Serial ICK, Dig. a. b. c. a.
1 1 1
1 \ I
1 ( \ 73
l L f
7, SAMPLE a. What is your exact address? Include House No., Street, Apt. No., or other identification.
ADORESS “Same as shown below 2 Different — Correet address ar check with office
b. House number and street
¢. Apt. No. of other unit designation
d. City State ZIP cone
8. MAILING a, Is this your mailing address? Enver ‘Some’ or spcerty if different. Include ZIP code.
| 4_iS TNS your matling address? Enver “'Same'’ or specify if differenr. inclu -
ADDRESS b. House number and street
€. Apt. No. of other unt designation
d. Cay State ZIP code
9, SPECIAL | Name , Cade @. Expected unis
PLACE

10. Interviewer’s name

1 Code

13. FINAL INTERVIEW STATUS

Enter the appropriate code (1-17) and the month and day for both placement ond pick-up for each week,

lla. RECORD OF CALLS

Code

Date Time

Date

1 ~ Diary placed or completed

am,
p.m.

NONINTERVIEW CODES

a.m.
p.m.

Type A

am,
p.m.

am.
p.m.

2 - Unable to contact
3 - Temporarily absent during entire reference week

am.
p.m,

4 ~ Refused
5 - Other - Specify in Notes

am.
p.m,

am,
p.m,

Type B

Ikb. DIARY DATES

6 — Vacant
7 = Occupied by persons with URE

WEEK 1

WEEK 2

Mo. |

T
1 2ay,

Mo.

8 - Under construction, not ready

From

—
rt
_

From

9 - Other - Specify in Nores

To 1

i

To

Type C
10 - Demolished

12. SUPERVISOR'S USE

11 - House or trailer moved
12— Converted lo permanent nonresidence

a. Reinterview

Initials

Date

13 — Merged
14 - Condemned

b. Observation

15 — Located on military base (post)

16 ~ CU no longer at sample address

17 — Other - Specify in Notes

a)

WEEK }

DIARY PLACEMENT

() ————— Code

Mo./Day

DIARY PICK-UP

Code

Mo./Day

Mf code 1, mark appropricte box

1 | Completed by respondent

2 (7) Partial recall

3 [> Total recall

14. AREA OFFICE NAME

WEEK 2

DIARY PLACEMENT

cote
Mo./Day
DIARY PICK-UP
S) cove
Mo./Day

W code 7, mark appropriate box
1 7] Completed by respondent
2 [7] Partial recall

3 || Total recall

NOTES



~ 12013 >

Port A-HOUSEHOLD CHARACTERISTICS

IF ty,

IN (TEM

FILi ITEMS 6-8 FOR EACH PERSON

After completing item 15e, continue with item 16 below

ADDEL,

8, FILL ITEMS 9-14 FOR THE F

SON

When did the ..

» family move?

stionnmire if

Propare a new qui

items 17 and 18 on the question:
naire for the app

@ ASK OF ALL UNITS @ || ASK IF MARKED 3. LIVING QUARTERS - ASK IF NOT APPARENT BY OBSERVATION
Ja. Are these living quarters — @ Ask if code 1 | ¢. Are these living quarlers | d. What percent |e. When did | 2a. Does this place have 10 acres or more? a, Do you have complete \b. Do you have direct c. Housing unit | d. Other unit
. 96 2 in stem lo used partly for business | of the you move kitchen facilities? | access from the 4 ter Hl <j
\([] Owned or being bought by or rented to others? expenses is j tothis | @6) 1 (_| YES ~Ask 2b(1) Me », | outside or through [on] House, apt, tlic 1 81] Quarters nol HU
someone in this unit (except b. Do you have a | > ~ If NO, mork “None.” | halt? 1 in rooming or
counted as address? 2 )NO — Ask 26) + acommon halt? 2()] HU in Special Place | boarding house
cooperative or condominium)? mortgage on > | a business - i VES — Are they farthis | = i
‘ 7 1
21” |A coaperative or condomtniom this property? \(C]No~ Skip tate | expense? ; , househald's | 31 Traler not in 1 8,__] Tentor trailer site
i ‘ b. During the past 12 months, did sales of 1 Special Place H =
owned or being bought by } Parl business H H exclusive use? { 7 [7] Other, not KU =
i it? . i crops, livestock, and other farm products ' Yes, direct 1 7
someone in this unit? 60) 1 yes Rented to oth fom this place amount to 1 heeoss | HU not specified i Describe 5
37; Rented for cash rent? ~ | Prentes to ote Month rom this place amount io — 1 [J Exclusive use! above — Describe |
Occupied without payment 277 pNO tJ Beth busses % a) (1) $50 or more? 1 YES 277} NO 21] Shared ; 5£7 No. through '
of cash cent? | others i Vea (2) $250 or mare? 1 YES 317} None ' another un.t '
~ 82024 > HOUSEHOLD RECORD | ~ 32 037 > CONSUMER UNIT RECORD CU No,
4. 3. 6. NAMC Last nome first 7. RELATIONSHIP. 8. HOUSEHOLD | 9. BIRTH 10. AGE JI.MARIFAL 412. SEX 13. RACE 4. ALF. : Mt more thon one CU, ranscribe cu No. from
. . MEMBER DATE STATUS MEXBER the first questionnaire for this household, |
5 c] What is the name of the head of this household? ToLINE 18. FOR ALL ADDITIONS AND
z 5 7 as What is . . .’s relationship to Is this... .'s | What was the] Enter o. Is. . -now ~ 1-Male 1—-White Ask if 16465 +e =
Q £ ge
e = — What are the names of ali other persons Siving the head of the household? usual place month and year | ot time 1 —Married? Black years old NUMBER DELETIONS TO THIS CU
g = | SS] or staying here? of residence? | of ...'s birth? | of firs+ dowed? 2 te | Black ov
= 2/as8 ‘ oe ‘ 2-Widowed? ~Femaie Negro Is... now Tronscribe In the appropriate column enter the
g = zs List all persons who uswolly live here ond ali] Example: Head, wife, son, _. interview 13_niverced? : the A 4 3 bine numbers date the change occurred for each
= SB )}ae persons who are temporarily absent, Be sure daughter-in-law, uncle, Mork YES if | Example: > 3-Other - in the Armes BS lotall . d
3 = fla2 to include infants under } year of oge. logger lodger's wife no usual 01-40, 4-Separated? Specify Forces? Ba [of oll persons person added or deleted in stem 17.
Ss 23/82 . - ' residence 12-105 5—Never in Notes SS Jin this CU ;
3S Z| BC) Drow a heavy line under name of Jost person a oa SS Vieam stem $ Addi: ons Deletions
= S PWS] sisted as first interview. married? Enter ; za ” ay
ane ete Code Yes | NO | MO. | yr. Enter code code Enter code | YES’ NO ff 2> mo. | Dav! yR. | MO. | DAY YR.
1 ' ~~ 7 ee | eo 1 1 ' '
1 | —_
T T ta ay eae _ 4 i as ——— TY
( \ 1 \
2 1 ot a
+--+ 4 + t
' 1 i 1 i '
3 po 1
eee ee a L 1 1 1 J)
j : ' H 1 Hl
1 t ,
4 _— f \ in f \
_ —— T T T 1 1 :
s i it
1 ' i 1 1 '
6 it 14
i _ - eee =) n pecfiecy = L L L i
1 i t ' 1 |
, _ i
— ' — - ns - t 7 y T
2) 2 it It
= a 7 oe 7 an ee na |
| ; t 12 oad t 1 T ‘
8 _ } ' ‘ ; (09 i t ' ‘
i nl : 2 ‘ i 1 |
@| [ns fee Vo
@ ASK AT WEEK 1 PLACEMENT @ ASK AT WEEK 2 PLACEMENT © ASK AT WEEK 1 AND
WEEK 2 PICK-UP = 12047 >
15a, | have listed... (read names from sem 6}. Have | missed ~ YES | NO | 15b. thave listed... (read names from item i). 1c. Is anyone else living or WEEK 1
- . re all of Hh ili iivi taying here? staying here now, includin
Any babies or small children? sss, rqyia Are all of these persons stili iiving or staying her staying ere om 8 15d, Were any household members away (J Yes
- : 1 . avernight for one day or more fast week -
— Any lodgers, boarders, or persons in your employ who live here? } oi 16 NC . Which persons have teft the househotd? (during the diary relerence period)? NO
For each person who has ie e
~ Anyone who usually lives here but is temporarily absent at present - | i nae ee ae i pe ee For each added person, complete if ves — Which persons?
Uaveling, at school, or ina hospital?, | |. . 1 cine a fae! irams 6-8. Tf YES inn item 8, fll Enter line numbers
j fill em 18, then ask item I5e. isso 91d, (DERTAINA CU Na, _ a
— Anyone else staying here? cot MO TYR. from item 160 ond fil! item 4 on L5e. Did anyone else, such as visitors stay _
; If the entire household has moved, usk i the origina! questionnaire un here overnight for one day or more last YES YES

opriote CU.

week (during the diary reference period)?

YES — How many such persons?
Enter the number of person

Na



16a. INTERVIEWER CHECK ITEM FOR ASK FOR EACH INDIVIDUAL OR GROUP OF RELATED PERSONS @ ASK AT ENO OF PART A ON
i 7 a. Bey cede PREPARED NOTES
ASSIGNING CU NO. ; _ ____NOT IDENTIFIED AS PART OF CUNO. “7 | ee EST Geo
I6b. Is ... financiatly independent \16c. What items does he pay ior 16d. Who pays for the remainder? ; eu ;
© Enter "7" in item 4 on the hines for head | that is, does ... pay for food himself? 1 two or more K —, gueeke CU tn the
of household, wife, never married clnidren, | oy shelter, and clothing with hsted items marked, es sign ousenole, OSs —
ond ony other person lised eho is 5 his own money? separate CU No, Otherwise, 19a. Daes more than one person in this
considered par! of that family. evel Hom 16d, _ household regularly contribute to
i LYES ~ Assign sepurote Cu : . ) Other CU in HH ~ Enter some CU No. in the expense of ilems such as food,
@ For oll other individuals or closely No. in item 4 [Food ~ | Clothing item 4. cleaning supplies, of papzy products?
related groups ask items 16b=d, as , a "Pers. SHH — Sowcify im Notes and
applicable. Filla separate ling far each. [UNO = Ask stem Ibe iJ Shelter i_| None ose anneenaiere CU Now in Tem den
= LL YES = Ask &
“VES — Assign separate CU oy ”  elath 7 Other CU in HH — Eater come CU No. rm =
For seporate CU's assign numbers rm . No. in item 4 1. | Food Fs Clothing stem 3. NO = SKIP 10 Part B
sequence, e.g., "2" for the second CU _ ff ot in HH — Specify in Notes and _
in the household. IT NG ~ Ask item i6c Lo] Sheltes (7: None : aan re ee CUlNe time
fone - ———-—| so eee A a eg a b. Does one person usually make
5 18 , 7 4. Spleens ee . a 7 the: CU im RH — Enter sume CU No. in ? a a _
ONT ED eee Wieancuahe a eae sans il 1 Food | Clothing a ele eae ‘ the purchases?
compiuting the questionnaire for ~ “Shelter None ~) Person not in HH ~ Specify in Notes ond 7) YES - Who?
CU No, 1. Enter in tem 6 af the NO ~ Ask item Iéc ~ 21 NF assign separate CL Na. ie item 4 Enter fine No. =
additional questionneirets; the + ~ a = — SSS er ouia Mic TE 7a 5
aames of afi ons in the CU, ‘YES - Assign separate CU earners C ther iv HH inter same lo. 19 rN
than fill sem TP, Hf more than 6 No. in item 4 Food [Clothing | item 4. 5 ees —
Cis STOP the interview and cull ! + Snel ia "| Person not in HK — Speeify in Nees and | NOTE:if ¥ :
the area 2flice far instructions | [NO ~Ask item 16e j Smelter |. | None ossign separate CU No. in item 4. usually makes the pur
ord the expens
@ After assigning CU Nos. in item 4 for all listed persons, 90 te item 17 vbowe. @ ered items.

~ 13.029 $ Port B ~ CONSUMER UNIT CHARACTERISTICS ~ Ask at Week | Placement

@ ASK ITEMS i, 2, AND3 FOR _ @ ASK ITEMS 4 AND 5 FOR HEAD — - ann me = om SE QUSE =
Fol). owe AND SPOUSE OF CU ONLY i 077 [Never attended Never attended — SKIP +0 §
1a. About how often do you (CU) shop Cod) hme SPOUSE OF CUO LR /€ oi! °
at the grocery store? ., —— 4a. Whal is the highest grade (year) of ; 219 Etememary Elementary
° (F02} | | Month regular school... (head. spouse) H VU pat amt art ap pet alt ot iE} ay 16h
ee as has ever attended? i sien High
the usual amount of your purchases ai | pr prot ose tsar t at ite! fut deat
7 0 pe | ~ - - -
the grocery store? - $00 per Shiseii College
‘include purchases made wilh Feod Stamps.) €a9) } [Month 13) tay "18h 446! lag vat )re faster
c. About how much of this amount was for . . . of higher _ ur higher =
food and nonalcoholic beverages? § ee ; ~
8 b. Did... complete that grade (year)? €13) Vl] ves 277NO €23) Loves 2i NO
d. About how much af this amount was ran ta ever completed a vocational =>
tor tobacco? a . of ja. Has... com| a vocational Qs) 0 :
{E09 tee training program? ‘in high school; as an €) 5) iT YEs @) ‘yi YES
e. About how much of this amount was —_ nLiCee, in business, nursing, Hada, 2 NOH SKIP 6 No SKIP
for alcoholic beverages? $ 0 G1 @None technical, or Armed Forces schooi.; i $s _
' in fi aay T
2a. Did you purchase any Federal Food Stamps b. ee the bea
7 1 DYES 227] NO = SKIP to a = Bt FICE Wo |
‘est month? ~ : 2.— Nursing, other health fields | :
. 5 | A a 3 — Trade or craft | i
b. 1* YES — What did you pay for them? SH eiearne

5 ~ Agriculture or hoi
6 - Ott

c. What was the value of exchange for the 8
stamps at the store?

}Don't know

3a. Do you (CU) own an automobile, truck, or YES "
other vehicie? Do not include any vehicle | 25 , 1196, G ?) NOTES
which is used entirely for business purposes. | eisyNOa skibie 4 === vote

b. How many?

—— Numer PROCESSING USE ONLY i 2 ee cones mee

c. Is this (are any of these) vehicle’s) yyes 2b,
used partially for business? :

“NO = SKIP to 4 t

© Jf more than one vehicle in Sh th 7) Don't know

§, How many?

__. Number
eon aids lial Sac ~~ | 6 What is your tetephone number? | '
for business j t |
7, Whal ts the best time of day to

1 ?

poral
e, What percent of your totat vehicie expense
is caunted as a business expense?

2.0