Form SC-1 Special Census Enumerator Questionnaire

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OMB No. 0607-0368: Approval Expires 05/31/2008
FORM SC-1
(5-11-2005)

COVERAGE

U.S. DEPARTMENT OF COMMERCE

County

Tract

Block

U.S. CENSUS BUREAU

any children, including foster children?
anyone away on business or vacation?
any roomers or housemates?
anyone else who had no other home?
Yes – Add person(s) to question 1, mark the "Add" box, and ask questions 2—6. Correct the POP count in question S5 on the front cover.
No – Continue with C 2.

QUESTIONNAIRE

Map Spot

Unit ID

➤

APPLY LABEL HERE

House No.

Street name, Rural route and box, or PO box

Special Census
Apt. No. or Location

On (Special Census date), were any of the people you told me about —
– away at college?
– away in the Armed Forces?
– in a nursing home?
– in a correctional facility?
Yes – Delete person(s) from question 1 by marking the "Cancel" box. Correct the POP count in question S5 on the front cover.
No – Continue with H1.

Continuation form(s) attached
Number of continuation
forms for this address

Location description

ZIP Code

House No.

Street name, Rural route and box, or PO box

Apartment No.

Location description

H1. Is this (house/apartment/mobile home) —
Owned by someone in this household with a mortgage or loan,
Owned by someone in this household free and clear (without a mortgage or loan),
Rented for cash rent, or
Occupied without payment of cash rent?

RECORD OF CONTACT

RESPONDENT INFORMATION
R1. Enter respondent’s name.

R2. In case we need to contact you,
what is your telephone number
and the best time to call?

First Name

Area code

Last Name

Lived here on
Special Census Day

Telephone number

–
Day

–
Evening

Type

R3. Respondent —
✗

Day

Is neighbor or other

Telephone

Type
Personal

p.m.

Telephone

:

a.m.

Personal

p.m.

Telephone

:

a.m.

Personal

p.m.

Telephone

NV = Left notice of visit

NC = No contact

Personal

OUTCOME CODES:

Outcome
a.m.

Personal
Telephone

Time

:

Personal

Moved in after
Special Census Day
Either

Month

B. POP on Special
Census Day

1 = Occupied
2 = Occupied – Continuation
3 = Vacant – Regular
4 = Vacant – Usual home elsewhere
5 = Uninhabitable/No longer exists
6 = Cannot locate/Outside boundary
7 = Duplicate
8 = Nonresidential
9 = Other

C. VACANT — Which category best

described this vacant unit as of
(Special Census date)?
For rent

D. PI

E. REP

F. CO

For sale only
01–97 = Total persons
00 = Vacant
98 = Delete
99 = POP unknown

Outcome

:

a.m.

:

a.m.

:

a.m.

p.m.

p.m.

p.m.

OT = Other

Hello, I’m (Your name) from the Census Bureau. (Show ID card.) Is this (Read address)?

S2.

I’m here to complete a Special Census questionnaire for this address. It should take about 7 minutes.
This notice (Hand respondent a Privacy Act Notice) explains that your answers are kept confidential.

G. REF

For seasonal, recreational,
or occasional use
For migrant workers

H. JIC1

No – Ask: Can you tell me where to find (Read address)? END INTERVIEW

Did you or anyone in this household live here on (Special Census date)?
Yes – Continue with question S3
No ➙ Skip to question S4

Rented or sold, not occupied

I. JIC2

S3.

Other vacant

Is this (house/apartment/mobile home) a vacation or seasonal home, or only occasionally occupied by
your household?

Yes ➙ Skip to items A, B, and C in the "Interview
Summary" block and refer to Card D.

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

Day

S4.
Crew Leader’s
initials
Month

No ➙ Skip to S5

On (Special Census date) was this unit —

Vacant ➙ Skip to items A, B, and C in the
"Interview Summary" block.

Day

S5.
Employee ID code

Time

S1.

Yes – Continue with question S2

CERTIFICATION
Enumerator’s signature

CI = Conducted interview

Day

INTRODUCTION

INTERVIEW SUMMARY
A. Status on Special Census Day

RE = Refusal

Month

Occupied by a different household? Using a knowledgeable
respondent, complete this questionnaire for the Special Census
Day household.

How many people were living or staying in this (house/apartment/mobile home) on (Special Census date)?

CLD number

Number of people
FORM SC-1 (5-11-2005)

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HOUSING

AA

ENUMERATOR

➤

C2.

State

SCO

Economics and Statistics Administration

C1. I need to make sure I have counted everyone who lived or stayed here on (Special Census date). Did I miss —
–
–
–
–

SC ID

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ENUMERATOR NOTE: For questions 2 through 6, prompt respondent with names if needed, for example, "Let’s start with Bob."
1. What is each person’s name? Start with the name of a
2. (Show Card A.) Which of these categories best describes how each person is
3. What is each
person who owns, is buying, or rents this
(house/apartment/mobile home).

person’s sex?
Mark ✗ ONE box.

related to (Read name of Person 1)?

Person 1

4. What was each person’s
age on (Special Census date)?
Print numbers in boxes.

Male

✗ Person 1

Age

MI

Female
What is this person’s
date of birth?

Last Name
Month

ENUMERATOR NOTE: It is important to ask BOTH questions 5 and 6 and show Cards B and C.

5. Are any of the persons that I have listed Mexican, Puerto
Rican, Cuban, or of another Hispanic or Latino group?
No, not Spanish/Hispanic /Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic /Latino –
What is this group?

Day

Person 2
MI

Last Name

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister

Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative – Specify relationship.

Male
Age

Female
What is this person’s
date of birth?
Month

Cancel

NONRELATIVE:
Roomer/boarder
Housemate/roommate

Add

Person 3
First Name

MI

Last Name

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister

NONRELATIVE:
Roomer/boarder
Housemate/roommate

Add

Person 4
First Name

MI

Last Name

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister

Unmarried partner
Foster child

Other
nonrelative

Cancel

Add

Person 5
First Name

MI

Last Name

Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative – Specify relationship.

Male
Age

Female
What is this person’s
date of birth?

Husband/wife
Natural-born son/daughter
Adopted son/daughter
Stepson/stepdaughter
Brother/sister

Add

NONRELATIVE:
Roomer/boarder
Housemate/roommate

No, not Spanish/Hispanic /Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic /Latino –
What is this group?

Day

Unmarried partner
Foster child

Other
nonrelative

What is this race?

Native Hawaiian

⎧
⎨
⎩

Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative – Specify relationship.

Male
Age

Female
What is this person’s
date of birth?

No, not Spanish/Hispanic /Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic /Latino –
What is this group?

Day

Unmarried partner
Foster child

Other
nonrelative

Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative – Specify relationship.

Filipino
Japanese
Korean
Vietnamese
Other Asian
What is this race?

Native Hawaiian

⎧
⎨
⎩

Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

White
Black, African Am., or Negro
Asian Indian
Chinese
American Indian or Alaska
Native – What is the name
of (your/. . .’s) enrolled or
principal tribe?

Filipino
Japanese
Korean
Vietnamese
Other Asian
What is this race?

Native Hawaiian

⎧
⎨
⎩

Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

White
Black, African Am., or Negro
Asian Indian
Chinese
American Indian or Alaska
Native – What is the name
of (your/. . .’s) enrolled or
principal tribe?

Filipino
Japanese
Korean
Vietnamese
Other Asian
What is this race?

Native Hawaiian

⎧
⎨
⎩

Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

Year of
birth

Male
Age

Female
What is this person’s
date of birth?

Day

Unmarried partner
Foster child

White
Black, African Am., or Negro
Asian Indian
Chinese
American Indian or Alaska
Native – What is the name
of (your/. . .’s) enrolled or
principal tribe?

Year of
birth

Month

Cancel

Filipino
Japanese
Korean
Vietnamese
Other Asian

Year of
birth

Month

NONRELATIVE:
Roomer/boarder
Housemate/roommate

No, not Spanish/Hispanic /Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic /Latino –
What is this group?

Day

Month

Cancel

White
Black, African Am., or Negro
Asian Indian
Chinese
American Indian or Alaska
Native – What is the name
of (your/. . .’s) enrolled or
principal tribe?

Year of
birth

Add

First Name

does each person consider himself/herself to be?

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Cancel

6. Now choose one or more races for each person. Which race or races

Other
nonrelative

No, not Spanish/Hispanic /Latino
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic /Latino –
What is this group?

White
Black, African Am., or Negro
Asian Indian
Chinese
American Indian or Alaska
Native – What is the name
of (your/. . .’s) enrolled or
principal tribe?

Filipino
Japanese
Korean
Vietnamese
Other Asian
What is this race?

Native Hawaiian

⎧
⎨
⎩

Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

Year of
birth

FORM SC-1 (5-11-2005)

§!+$¤

ENUMERATOR NOTE: Refer to S5 on the cover. If the number of people is more than 5, add additional household members to Form SC-1(SUPP), Continuation Form.

001003

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First Name

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