Various Pretesting Activities (see attached list)

Draft 1 (1-6-2009)

OMB No. 0607-0725: Approval Expires 8/30/2010

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Individual Census Report
Use a blue or black pen.

6. Do you live or stay in this facility MOST OF
THE TIME?

Start here

Yes
No

1. What is your name? Print name below.

7. Besides this facility, what is the full address of a

Last Name

place where you sometimes live or stay?
First Name

Please complete all that apply

MI

Street address number

2. What is your sex? Mark I
J ONE box.
K
Male

Street name

Female

3. What is your age and what is your 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
Day
Year of birth
Month
Apartment number

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and
Question 5 about race. For this census, Hispanic origins are not races.
Rural route address

4. Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

County

5. What is your race? Mark I
J
K one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

City

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

State or foreign country

ZIP Code

Some other race — Print race. C
Form DY-20(X1) (1-6-2009)

USCENSUSBUREAU

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Tone Pantone Process Cyan - 10%, 25%, 50% and 100% - Base Black ink

March 17, 2010

DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

Dear Resident:
This is your official 2010 Census form. We need your help to count everyone in the United States.
It is important that everyone be counted, regardless of where they may be living at the time of the
census. This Individual Census Report is to be used to count people who are currently living or
staying in group quarters, such as college or university dormitories, nursing homes, group homes,
emergency and transitional shelters for people experiencing homelessness, and other such locations.
Please follow the instructions you were given when you received this form for returning it to
the appropriate person.
Your answers are important. Census results are used to decide the number of representatives each
state has in the U.S. Congress. The amount of government money received also depends on these
answers. That money is used for services for children and the elderly, roads, and many other local
needs. As allowed by law, your census data becomes public after 72 years. This information can be
used for family history and other types of historical research.
Your answers are confidential. This means the Census Bureau cannot give out information that
identifies you. Your answers will only be used for statistical purposes, and no other purpose. Please
visit our Web site at and click on "Protecting Your Answers" to learn
more about our privacy policy and data protection.
Sincerely,

Steve H. Murdock
Director, U.S. Census Bureau

Thank you for completing your official 2010 Census form.
FOR OFFICIAL USE ONLY
The U.S. Census Bureau estimates that, for the average respondent,
this form will take about 5 minutes to complete, including the time for
reviewing the instructions and answers. Send comments regarding
this burden estimate or any other aspect of this burden to: Paperwork
Reduction Project 0607-0919-C, U.S. Census Bureau, AMSD-3K138,
4600 Silver Hill Road, Washington, DC 20233. You may e-mail
comments to ; use "Paperwork Project
0607-0919-C" as the subject.
Respondents are not required to respond to any information
collection unless it displays a valid approval number from the Office
of Management and Budget.

GQ Control Number

A. PN

B. JIC1

D. Answered By:

Form DY-20(X1) (1-6-2009)

C. JIC2

Respondent

Other

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