D-1(E)(SUPP) Enumerator-NRFU Supplemental

Draft 4 7/24/2008
OMB No. 0607-0919-C: Approval Expires 12/31/2011

NOTES

Form

of

Form(s)

TRANSCRIBE UNIT ID FROM THE LABEL ON D-1(E) OR D-15 QUESTIONNAIRE

REP

Unit ID

LCO

State

County

Tract

Block

AA

Map Spot

CONTINUATION FORM FOR
ENUMERATOR
QUESTIONNAIRES

D-1(E)SUPP - Tone prints in Pantone Process Cyan - 10%, 25%, 50% and 100%

–

D-1(E)SUPP - Base print in Black ink

NOTES

USCENSUSBUREAU

§n#"¤
770201

Form D-1(E)SUPP (7-24-2008)

Draft 4 7/24/2008

Person No.
First Name

MI

Last 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.

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

Is (Name)
male or
female?

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate
Unmarried partner
Other nonrelative

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
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 No.
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

Son-in-law or
daughter-in-law

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate
Unmarried partner
Other nonrelative

Age on
April 1, 2010
DATE OF BIRTH
Month
Day

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

Son-in-law or
daughter-in-law

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate
Unmarried partner
Other nonrelative

Age on
April 1, 2010
DATE OF BIRTH
Month
Day

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

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

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

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

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

Son-in-law or
daughter-in-law

Male
Female

Age on
April 1, 2010
DATE OF BIRTH

Other relative
Roomer or boarder
Housemate
or roommate
Unmarried partner
Other nonrelative

Month

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

Person No.
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

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

Male
Female

Age on
April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth

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

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

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?
FORM D-1(E)SUPP (7-24-2008)

Other Pacific Islander — What is that group?

White

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

Other Asian — What is that group? C

➙

Some other race — What is that group?

Person No.

Other Pacific Islander — What is that group?

White

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

Other Asian — What is that group? C

➙

Some other race — What is that group?

Year of birth

Person No.

6.

Other Asian — What is that group? C

Other Pacific Islander — What is that group?
➙

7.

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

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

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

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

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

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

§n##¤
770202

D-1(E)SUPP - Tone prints in Pantone Process Cyan - 10%, 25%, 50% and 100%

Who else lived or stayed here on April 1, 2010?

D-1(E)SUPP - Base print in Black ink

1.