DX-15 Enumeration at Transitory Locations

RECORD OF CONTACT
Type

Day

Month

Time

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Outcome

OUTCOME CODE: CI=Conducted Interview
State

County

2.

2. Is (Name) male or female? Mark I
J
K ONE box.
Male
AA

Map Spot

Female

Unit ID

Last Name

3a. What is (Name’s) date of birth? Print numbers in boxes.
Month

(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, DX-1(F).) This Privacy Notice
explains that your answers are kept confidential. I’ll be referring to this Information Sheet
while we fill out the questionnaire.

R2. In case we need to contact you, what is your telephone number

S2. Including yourself, how many people are living or staying in this (RV/boat/room/unit)

and the best time to call?

Evening

Age

No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

HOUSING

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

H1. What is the mailing address of this unit?

Household Member – Lives Here
Neighbor
Landlord
Other Proxy

House No.

Street name, Rural Route and box, or PO box

are not races. Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

INTERVIEW SUMMARY
Apt. No. or Location

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

POP
State

City

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

ZIP Code

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on?

H2. Do you or does someone in this household own this (RV/boat/room/unit) with a

CERTIFICATION

Enumerator’s signature

Day

Crew Leader’s initials

CLD number

mortgage or loan, including home equity loans; own it free and clear; rent it; or
occupy it without having to pay rent?

Asian Indian
Japanese

Own with a mortgage or loan
Own free and clear
Rent
Occupy without payment of rent

Month

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, for example, Fijian, Tongan, and so on?

NOTES
Applicant ID

Native Hawaiian
Samoan

Day

FOR OFFICIAL USE ONLY
JIC1

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

5. Please look at List C and choose one or more races. For this census, Hispanic origins

01–20 = Total persons

Female

Month

Day

Year

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

4. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?

Either

R3. Respondent —

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

than 1 year old.

Number of people =
Day

Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative

3. Is (Name) male or female? Mark I
J
K ONE box.

3b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

who have no other place they usually live?
–

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister

4a. What is (Name’s) date of birth? Print numbers in boxes.

Number

01 = Occupied

Year

Last Name
Please look at List A. How is (Name) related to (Person 1’s Name)? Mark I
J
K ONE box.

Male

S1. I will complete a census questionnaire for all the people staying at this

A. Status of unit:

Day

INTRODUCTION

Address if proxy

MI

MI

First Name

Block

MI

–

1. What is the name of another person staying here who has no other place he/she usually lives?
First Name

Last Name
LCO

R1. Enter Respondent’s name

Area Code

Person 2

ADDRESS INFORMATION

RESPONDENT INFORMATION
First Name

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.

2008 Census Dress Rehearsal
Transitory Location Questionnaire

a.m.
p.m.

Personal

1. I have a few questions about each of the people who are living or staying here. If an

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is that group? C

than 1 year old.
Age

5. Please look at List B. Is (Name) of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, (for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)?
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

6. Please look at List C and choose one or more races. (For this census, Hispanic origins
are not races.) Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?
White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is that group? C

JIC2
Form DX-15 (7-31-2007)

USCENSUSBUREAU

OMB No. 0607-0919-DR; Approval Expires 8/30/2010

➜

If more people were counted in Question S2 on the front page, continue with Person 2.

➜ If more people were counted in Question S2 on the front page, continue with Person 3.

§qT"¤
805101
Draft 8 (7-31-2007)

Person 3

Person 4

Person 5

1. What is the name of another person staying here who has no other place he/she usually lives?

1. What is the name of another person staying here who has no other place he/she usually lives?

1. What is the name of another person staying here who has no other place he/she usually lives?

First Name

First Name

MI

Last Name
2. Please look at List A. How is (Name) related to (Person 1’s Name)? Mark I
J
K ONE box.
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
Other relative

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

Female
Day

Last Name
Please look at List A. How is (Name) related to (Person 1’s Name)? Mark I
J
K ONE box.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister

Male

4a. What is (Name’s) date of birth? Print numbers in boxes.
Month

First Name

Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. Is (Name) male or female? Mark I
J
K ONE box.

3. Is (Name) male or female? Mark I
J
K ONE box.
Male

2.

MI

Last Name
Please look at List A. How is (Name) related to (Person 1’s Name)? Mark I
J
K ONE box.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister

Male

Female
Day

Person 6

Father or mother
Grandchild
Parent-in-law
Son-in-law or daughter-in-law
Other relative

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

First Name

MI

Last Name

Date of Birth
Month
Day

Age on April 1, 2008
Year

Month

Year

Person 7

Female

4a. What is (Name’s) date of birth? Print numbers in boxes.
Day

First Name

MI

Year
Last Name

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less
than 1 year old.

than 1 year old.
Age
No, not of Hispanic, Latino, or Spanish origin

Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, (for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)?
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Age
5. Please look at List B. Is (Name) of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

No, not of Hispanic, Latino, or Spanish origin

Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, (for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)?
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

5. Please look at List B. Is (Name) of Hispanic, Latino, or Spanish origin?

Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, (for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)?
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin —
What is that origin? C

6. Please look at List C and choose one or more races. (For this census, Hispanic origins

6. Please look at List C and choose one or more races. (For this census, Hispanic origins

6. Please look at List C and choose one or more races. (For this census, Hispanic origins are

are not races.) Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

are not races.) Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

not races.) Is (Name) White; Black, African American, or Negro; American Indian or Alaska
Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

Date of Birth
Month
Day

Person 8

Age on April 1, 2008
Year

First Name

MI

Last Name

Date of Birth
Month
Day

Person 9

Age on April 1, 2008
Year

First Name

MI

Last Name
Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or
another Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or
Chamorro, Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is that group? C

➜ If more people were counted in Question S2 on the front page, continue with Person 4.

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or
another Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or
Chamorro, Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is that group? C

➜ If more people were counted in Question S2 on the front page, continue with Person 5.

Related to Person 1?

Sex
Male
Female

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less
than 1 year old.

Age

5. Please look at List B. Is (Name) of Hispanic, Latino, or Spanish origin?

Sex
Male
Female

Yes
No

3. Is (Name) male or female? Mark I
J
K ONE box.

4a. What is (Name’s) date of birth? Print numbers in boxes.
Month

Year

2.

MI

I have a few questions about each of the other people living or
staying in this (RV/boat/room/unit).

Related to Person 1?
Yes
No
Sex
Male
Female

Related to Person 1?
Yes
No
Sex
Male
Female

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or
another Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or
Chamorro, Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is that group? C

Date of Birth
Month
Day

Person 10

Age on April 1, 2008
Year

First Name

MI

Last Name

Date of Birth
Month
Day

Age on April 1, 2008
Year

Related to Person 1?
Yes
No
Sex
Male
Female

Related to Person 1?
Yes
No

➜ If more people were counted in Question S2 on the front page, continue with Person 6.

§qT#¤
805102
Draft 8 (7-31-2007)