SC-2 Special Place Questionnaire

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OMB No. 0607-0368: Approval Expires 05/31/2005
FORM SC-2
(12-3-2002)

U.S. DEPARTMENT OF COMMERCE

SC ID

State

SCO

County

Tract

Block

Economics and Statistical Administration

U.S. CENSUS BUREAU

AA

SPECIAL CENSUS
QUESTIONNAIRE

Map Spot

Ó

INDIVIDUAL

APPLY LABEL HERE

Ó
GQ Type

GQ Name

House No.

Special Census

Unit ID

Street name, Rural route and box, or PO box

City

ZIP Code

State

⊕

Person Number

S1.

Hello, I’m (Your name) from the Census Bureau. (Show ID card.)

S2.

We are taking a special census of (Area) and I would like to ask you a few questions. It should
take about 5 minutes. This notice (Hand respondent a Privacy Act Notice) explains that your
answers are kept confidential.

S3.

If GQ Type Code in label is 996 or 997, ASK Question S4; otherwise SKIP to Question 1 on page 2.
Do you live or stay here MOST OF THE TIME?

Yes – Go to Question 1 on page 2
No – Thank respondent, end interview, and skip to Interview Summary block and mark the UHE box.

RESPONDENT INFORMATION
R1. Enter respondent’s name if different than resident/client.

R2. Enter the facility area code and
telephone number

First Name

Area code

Last Name

Telephone number

–

–

INTERVIEW SUMMARY
A. CI

B. PI

C. UHE

D. CO

E. JIC1

F. JIC2

G. JIC3

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

Month

Employee ID code

Day

Crew Leader’s
Month
initials

Day

CLD number


002001

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SC-2 - Prints GREEN, Pantone 340

S4.

SC-2 - Base prints BLACK

INTRODUCTION

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1. What is your name?
Last Name

First Name

MI

2. Mark ✗ sex of person.
Male

Female

3. a. What was your age on (Special Census Date)?
Age

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SC-2 (6-6-2002) - Base prints BLACK

b. What is your date of birth?
Print numbers in boxes.
Month
Day
Year of birth

ENUMERATOR NOTE: It is important to ask BOTH questions 4 and 5 and show Cards B and C.

4. (Show Card B.) Are you 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?

5. (Show Card C.) Now choose one or more races. Which race or races do you consider yourself to be?
Filipino
Japanese
Korean
Vietnamese
Other Asian

Native Hawaiian





Guamanian/
Chamorro
Samoan
Other Pacific
Islander
Some other race

SC-2 (6-24-2002) - Prints GREEN, Pantone 340

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?

What is this race?


002002

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