Form D-15 Census 2010 Transitory Location Questionnaire

NOTES

RECORD OF CONTACT

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Type

Month

Day

TRANSITORY LOCATION QUESTIONNAIRE

Outcome

Time
a.m.
p.m.

Personal
OUTCOME CODE: CI=Conducted Interview

LCO

State

County

Tract

Block

Map Spot

AA

RESPONDENT INFORMATION
R1.

R2.

(Ask or verify)What is your name?

Area Code

MI

First Name

What is your phone number and best time to call?
Number
–

Last Name

Day

–
Evening

Either
Are there any continuation forms for this address?

Respondent Type—

➤

APPLY LABEL HERE

Yes ➙ Number of forms
No

Household member – Lived here on April 1, 2010
Household member – Moved in after April 1, 2010
Neighbor or other proxy

INTERVIEW SUMMARY
INTRODUCTION
A.Status of Unit:
01 = Occupied

C.

B.POP

English
Spanish
Other – Specify language number from flashcard ➙

01-49 = Total persons

14
D.JIC1

What language was the majority of the interview conducted in?

S1.

I will complete a census questionnaire for all the people staying at this (RV/boat/room/unit) who have no other place
they usually live and sleep. This should take about 10 minutes. (Hand respondent the Information Sheet.) The first part
explains that your answers are confidential. I’ll be referring to this handout while we fill out the questionnaire.

S2.

Including yourself, how many people are living or staying in this (RV/boat/room/unit) who have no other place they
usually live?

E.JIC2

Number of people =

CERTIFICATION
HOUSING
I certify that the entries I have made on this questionnaire are
true and correct to the best of my knowledge.

Crew Leader’s initials

H1.

What is the mailing address of this unit?
House No.

Enumerator’s signature

Employee ID

Street name, Rural Route and box, or PO box

D-15 - Tone prints in Pantone Process Cyan - 10%, 25% and 50%

R3.

➤

Address of proxy

CLD number

Apt. No. or Location
Month

Day

Day

City

H2.

State

ZIP Code

Do you or does someone in this household own this (RV/boat/room/unit) with a mortgage or loan, including home equity loans;
own it free and clear; rent it; or occupy it without having to pay rent?
Own with a mortgage or loan
Own free and clear
Rent
Occupy without payment of rent

USCENSUSBUREAU
PID Barcode
HOUSING

770101

§n""¤

Test Barcode: 7 730 01 Producion Barcode: 1 730 01

FORM D-15 (6-24-2008)

D-15 - Base print in Black ink

Month

Draft 1 6/24/2008

Person 1
First Name

2.

Please look at list B on the Information
Sheet. How is (Name) related to (Read name
of Person 1)?

3.

Mark I
J
K ONE box.

Mark I
J
K ONE box.

I
J
K Person 1

Is (Name)
male or
female?

Male
Female

MI

4.

What was (Name’s) age on
April 1, 2010? What is this
person’s date of birth?
Please report babies as age 0
when the child is less than 1
year old.
Print numbers in boxes.
Age on
April 1, 2010
DATE OF BIRTH
Month

Last Name

Day

5.

Please look at List C. Is (Name) of Hispanic, Latino, or
Spanish origin?
Read if necessary:
Examples of another Hispanic, Latino, or Spanish origin include
Argentinean, Columbian, Dominican, Nicaraguan, Salvadoran,
Spaniard, and so on.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

Year of birth

Person 2
First Name

MI

Last Name

Person 3
First Name

MI

Last Name

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law

Son-in-law or
daughter-in-law

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate

DATE OF BIRTH
Month
Day

Unmarried partner
Other nonrelative

Son-in-law or
daughter-in-law

Age on
April 1, 2010

Other relative
Roomer or boarder
Housemate
or roommate

Age on
April 1, 2010
DATE OF BIRTH
Month
Day

Unmarried partner
Other nonrelative

Please look at List D and choose one or more races. For this census, Hispanic origins are not races.
What is (Name’s) race?

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Year of
birth

First Name

MI

Last Name

Person 5
First Name

Last Name

MI

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law

Son-in-law or
daughter-in-law

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate

DATE OF BIRTH
Month

Unmarried partner
Other nonrelative

Son-in-law or
daughter-in-law
Other relative
Roomer or boarder
Housemate
or roommate
Unmarried partner
Other nonrelative

Age on
April 1, 2010

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

Day
Year of
birth

Male
Female

Age on
April 1, 2010

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

DATE OF BIRTH
Month
Day
Year of
birth

FORM D-15 (6-24-2008)

PID Barcode

Other Asian — What is that group? C

Other Pacific Islander — What is that group?

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian or
Chamorro

Samoan

In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No

Other Asian — What is that group? C

Other Pacific Islander — What is that group?
➙

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No

Other Asian — What is that group? C

Other Pacific Islander — What is that group?
➙

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Some other race — What is that group?

In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No

➙

Some other race — What is that group?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No

Other Pacific Islander — What is that group?

Black,
African American,
or Negro

Some other race — What is that group?

Person 4

Mark I
J
K all reasons that apply.

Other Asian — What is that group? C

White

Does (Name) sometimes live
or stay somewhere else for
any of these reasons? —
Read response categories.

➙

Some other race — What is that group?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

7.

Read if necessary:
Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
Examples of other Pacific Islander groups include Fijian, Tongan, and so on.

Some other race — What is that group?

Year of
birth

Male
Female

6.

In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No

Other Asian — What is that group? C

Other Pacific Islander — What is that group?
➙
770102

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D-15 - Tone prints in Pantone Process Cyan - 10%, 15, 25% and 50%

I have a few questions about each of the people who
are living or staying here. If an owner or renter of this
(RV/boat/room/unit) lives here, please give me that
person’s name first. If an owner or renter does not live
here, start with the name of any adult living here.

D-15 - Base print in Black ink

1.