Various Demographic & Decennial Areas Pretesting Activities

OMB No. 0607-XXXX: Approval Expires XX/XX/XXXX

DX-1301

U.S. DEPARTMENT OF COMMERCE

PERSON FOLLOWUP QUESTIONNAIRE

FORM
(7-24-2009)

Economics and Statistics Administration

U.S. CENSUS BUREAU

CENSUS COVERAGE MEASUREMENT
2009 Operational Test
CLUSTER NO.
CCM Address
Block

LCO
MSN

WMSN

CENSUS Address
Block

CMSN

CID

Hello, I’m (Your name) from the U.S. Census Bureau. Here is my
identification. As part of the census, we are contacting
households to make sure we counted everyone correctly.
Here is a letter explaining our interview and information we
will refer to later.

Possible Reasons for Followup:
• The last time we were here, we didn’t get enough detailed information
to know where some household members should have been counted
in the census.
CCM Roster – PI interview day:

Census Roster – Census Day: Oct 1, 2008

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

8.

8.

9.

9.

10.

10.

11.

11.

12.

12.

• We have two names and we aren’t sure if they refer to the same
person or different people.
• We need more detailed address information about where some of the
household members stayed during 2008 – things like street address.
Crew Leader name

FR code

Interviewer name

FR code

Reassignment reason

Notes
NOTICE

If found, please either call 1–301–763–3301 collect
to arrange for pickup or mail to:
Census Coverage Measurement
U.S. Census Bureau
4600 Silver Hill Rd
Washington, DC 20233-5700

NOTES

FORM DX-1301 (7-24-2009)

2

3

Section A – INTRODUCTION
Followup for
1. Have you heard of
?

1
2
3

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

1
2
3

2
3

1
2
3

2
3

1
2
3

2

FORM DX-1301 (7-24-2009)

1
2

Yes – Go to 1c
No – Go to 1c

1d. Respondent type

Name

1

Number and street

2

4

OE

Yes – Go to NEXT PAGE.
No – Skip to 1c

1
2

Yes – Go to 1c
No – Go to 1c

Name

1

Number and street

2
3

OE

CL

1
2

4

OE

Yes – Go to NEXT PAGE.
No – Skip to 1c

1
2

Yes – Go to 1c
No – Go to 1c

Name

1

Number and street

2
3

OE

CL

1
2

4

OE

Yes – Go to NEXT PAGE.
No – Skip to 1c

1
2

Yes – Go to 1c
No – Go to 1c

Name

1

Number and street

2
3

OE

CL

1
2

4

OE

Yes – Go to NEXT PAGE.
No – Skip to 1c

1
2

Yes – Go to 1c
No – Go to 1c

Name
Number and street

1
2
3

OE

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

CL

1

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

Yes – Go to NEXT PAGE.
No – Skip to 1c

1c. What is your name
and address?

3
OE

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

1

2

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

1a. Do you know (name) well 1b. Do you know who lived at
enough to answer
questions about where
he/she was living in 2008
and other places where
he/she stayed?
on
?
1

Yes – Go to 1a.
Yes, respondent is (name) –
Go to NEXT PAGE.
No – Skip to 1b
CL

1

Age

Print corrected name if needed

CL

1
2

4

OE

Yes – Go to NEXT PAGE.
No – Skip to 1c

1
2

Yes – Go to 1c
No – Go to 1c

Name
Number and street

1
2
3

OE

CL

OE

4

Resident
Neighbor
Landlord
Other – Specify

Resident
Neighbor
Landlord
Other – Specify

Resident
Neighbor
Landlord
Other – Specify

Resident
Neighbor
Landlord
Other – Specify

Resident
Neighbor
Landlord
Other – Specify

Resident
Neighbor
Landlord
Other – Specify

1e. Notes (Record anything respondent
tells you about (name), who lived at
the address, or who might be a
more knowledgeable respondent).

4

Section B – POSSIBLE MATCH/DUPLICATE
1. We are trying to find out if the names we have refer to the same person.

2. What is the relationship between them?
1

Are

2
3

and
the same person?
1
2
3

4

Yes, same person – Complete Section C for first person only.
No, different people – Go to 2
DK/REF – Complete Section C for person Respondent knows.

5

CL

OE
6

Notes

FORM DX-1301 (7-24-2009)

Jr/Sr, Father/Son, Mother/Daughter . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Twins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Neighbors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other – Specify

DK – Describe how Respondent knows they are different people

REF

⎫
⎬
⎭

Complete Section C
for both people.

5

Section C – PERSON QUESTIONS
Now, we’ll talk about

.

1. Did you/

1g. Please look at the calendar on the back
of the letter. During 2008, when did
you/he/she live or stay at this address?
Please provide as specific dates as possible.

live or stay at
anytime in 2008?

FROM

TO

mm / dd / 2008

1

Yes – Skip to 1g

2

No – Go to 1a
DK/REF – Go to next known
person. If last person,
end interview.

mm / dd / 2008
CL

3

1a. At what address did you/he/she
live in 2008?
Number and street

1d. Is that place a house or
apartment or another type of
place like those shown on the
list I gave you? The list is on
the back of the letter.

Apt/Unit #
City

1
ZIP Code

State

2
2

DK/REF – Probe for street, city, state.

1b. (Ask or verify) Is that place more than
1 mile away from

3
4
5
6
7
8
9

1
2
3

Yes, more than a mile away
No, less than a mile away
DK/REF

1e. What are the names of any
other people who lived with
you/him/her at this address?
First name

Last name

House/Apartment/Mobile home/
First name
Last name
Condo/Townhouse
College dorm/Residence hall/
Sorority/Fraternity house . . .
1
DK/REF
Military barracks/Ship . . . . .
Nursing home . . . . . . . . . SKIP 1f. What are the names of
neighbors who lived nearby?
Skilled nursing unit in AL . . to
First name
Last name
1g
Independent/Assisted Living
Correctional facility . . . . . .
First name
Last name
Group home . . . . . . . . . .
Other – Specify
1
DK/REF

}

Go to 1g at top of next column.
10

DK/REF

1c. What are the landmarks or cross
streets closest to that place?

1h. (Ask or verify) During 2008, did you/he/she
live at this address all year, move, or go
back and forth between addresses?
1
2

3

1
2
3
4

CL
FORM DX-1301 (7-24-2009)

OE

DK/REF

1

Before 10/1

2

On 10/1

3

After 10/1

1

Before

2

On

3

After

Go back and forth

Most of the time?
Half of the time?
Less than half the time?
Short stays?

5
6

Daytime only,
didn’t spend nights?
Certain days of week?
Su
Th

M
F

1j. (Ask or verify) Were you/Was he/she at this
address on Wednesday, October 1st?
2
3

1

All year
Move – Was the move

1i. (Ask or verify) During 2008, did you/he/she stay at
this address: Mark (X) all that apply.

1

NOTES

OE

Yes
No
DK/REF

Tu
Sa

W

6

Section C – PERSON QUESTIONS – Continued
2a. What is the address of that place?
2. Did you/
1

live anywhere else in 2008?
1
2
3

Same as

Name’s location

2c. What are the landmarks or
cross streets closest to
that place?

SKIP
to 2g

Apt/Unit #

}

First name

Last name

First name

Last name

DK/REF
1

DK/REF

2d. Is that place a house or
apartment or another type
2f. What are the names of
of place like those shown
neighbors who lived nearby?
on the list I gave you?
ZIP Code
State
First name
Last name
1
House/Apartment/Mobile home/
Condo/Townhouse
First name
Last name
2
College dorm/Residence hall/
Sorority/Fraternity house . . .
2
DK/REF – Probe for street, city, state.
3
Military barracks/Ship . . . .
1
DK/REF
2b. (Ask or verify) Is that place more than
4
Nursing home . . . . . . . . . SKIP
1 mile away from
to
5
Skilled nursing unit in AL . . 2g
6
Independent/Assisted Living
7
Correctional facility . . . . . .
Group home . . . . . . . . . . .
8
9
Other – Specify
1
Yes – more than a mile away
Notes
No – less than a mile away
2
DK/REF
10
DK/REF
3
City

}

CL

OE

3. During 2008, did you/

3a. What is the address where
you/he/she lived while in college?

attend college?
1
2
3

3c. What are the landmarks or
cross streets closest to the
place where you/he/she lived?

SKIP
to 4

1

}

Apt/Unit #

1

State

ZIP Code
1

2

DK/REF – Probe for street, city, state.

2
3

3b. What is the name of the college or
university?

CL

OE

1

DK/REF

First name

Last name

First name

Last name

1

3d. Is that place a dormitory,
residence hall, sorority or
fraternity house?

City

FORM DX-1301 (7-24-2009)

3e. What are the names of any
other people who lived with
you/him/her at that place?

Number and street

Yes – Go to 3a
No
SKIP to 4
DK/REF

DK/REF

2g. During 2008, when did you/he/she live or stay at
that place? Please provide as specific dates as possible.
FROM

TO

mm / dd / 2008

Number and street
1

Yes – Go to 2a
No
SKIP to 3
DK/REF

2e. What are the names of any
other people who lived with
you/him/her at that place?

}

Yes, dorm or residence hall SKIP
Yes, sorority/fraternity house to 3g
No, other college
housing – Specify

3f. What are the names of
neighbors who lived nearby?
First name

Last name

First name

Last name

DK/REF
Notes

5

No, not college housing
DK/REF

Before

1
2

2

On

3

After

Back and forth

2i. (Ask or verify) During 2008, did you/he/she stay at
that place: Mark (X) all that apply.
5
Daytime only,
1
Most of the time?
didn’t spend nights?
Half of the time?
2
6
Certain days of the week?
Less
than
half
the
time?
3
4
Short stays?
Tu
W
M
Su
Th
F
Sa
2j. (Ask or verify) Were you/Was he/she there
on Wednesday, October 1st?
Yes

1

2

No

3

DK/REF

3g. During 2008, when did you/he/she live or stay at
that place? Please provide as specific dates as possible.
FROM

TO

mm / dd / 2008

mm / dd / 2008

3h. (Ask or verify) Did you/he/she stay at that place:
Mark (X) all that apply.

2
3
4
5

1
4

2h. (Ask or verify) Did you/he/she move or go back
and forth between places?
1
Move – Was
After 10/1
On 10/1 3
the move
1
Before 10/1 2

1

DK/REF

mm / dd / 2008

Winter Semester
6
2007–2008?
Spring Semester 2008? 7
Summer Semester 2008?
Fall Semester 2008?
Winter Semester
2008–2009?

Daytime only,
didn’t spend nights?
Certain days of the week?
Su
Th

M
F

Tu
Sa

W

7

Section C – PERSON QUESTIONS – Continued
Do not include short hotel stays.

A1. What is the address of that place?
Same
as

1

During 2008, did you/

Name’s location

SKIP
to F1

Number and street

1

Apt/Unit #

4. Live or stay part of the
time with another
relative?
1
Yes – Go to A1
No
2
Go to 5
DK/REF
3

}

5. Live or stay someplace
else because of
military service?
1
Yes – Go to A1 or A2
2
No
3
DK/REF Go to 6

}

6. Live or stay someplace
else because of a job?
1
Yes – Go to A1 or A2
No
2
DK/REF Go to 7
3

}

2
3

2
3

City

3
4
ZIP Code

State

5
6
7

DK/REF – Probe for street, city, state.

2

B1. What are the landmarks or cross
streets closest to that place?

8
9

10

}

SKIP
to
F1

A2. What is the address of that place?

Last name

1

First name

Last name

First name

Last name

Same
as

1

Name’s location

SKIP
to F2

3

State

ZIP Code

5
6

2

DK/REF – Probe for street, city, state.

B2. What are the landmarks or cross
streets closest to that place?

7
8
9

10

DK/REF
Notes

1

OE

Move – Was
the move
Back and forth

1

Before 10/1 2

On 4/1

3

After 10/1

H1. (Ask or verify) During 2008, did you/he/she stay at that place:
Mark (X) all that apply.
5
Daytime only,
1
Most of the time?
didn’t spend nights?
Half of the time?
2
Certain days of the week?
Less than half the time? 6
3
4
Short stays?
Tu
W
M
Su
Th
F
Sa
I1. (Ask or verify) Were you/Was he/she there on
Wednesday, October 1st?

DK/REF

House/Apartment/Mobile
home/Condo/Townhouse
College dorm/Residence hall
Sorority/Fraternity house . .
Military barracks/Ship . . . .
Nursing home . . . . . . . . .
Skilled nursing unit in AL . .
Independent/Assisted Living
Correctional facility . . . . . .
Group home . . . . . . . . . .
Other – Specify

.
.
.
.
.
.
.

}

SKIP
to
F2

D2. What are the names of any
other people who lived with
you/him/her at that place?
First name

Last name

First name

Last name

1

DK/REF

DK/REF

E2. What are the names of
neighbors who lived nearby?
First name

Last name

First name

Last name

1

CL

mm / dd / 2008

G1. (Ask or verify) Did you/he/she move or go back
and forth between places?

2

E1. What are the names of
neighbors who lived nearby?

TO

mm / dd / 2008

1

DK/REF

DK/REF

C2. Is that place a house or
apartment or another type of
place like those shown on the
list I gave you?

4

}

First name

FROM

1

City

Yes – Go to A1 or A2
No
DK/REF Go to 9

Last name

F1. During 2008, when did you/he/she live or stay at
that place? Please provide as specific dates as possible.

Yes

2

No

3

DK/REF

Notes

2

}

First name

DK/REF

1

Apt/Unit #

Yes – Go to A1 or A2
No
Go to 8
DK/REF

FORM DX-1301 (7-24-2009)

.
.
.
.
.
.
.

D1. What are the names of any
other people who lived with
you/him/her at that place?

1

1

8. Was there any other
place you/he/she
stayed often?
1

2

House/Apartment/Mobile
home/Condo/Townhouse
College dorm/Residence hall
Sorority/Fraternity house . .
Military barracks/Ship . . . .
Nursing home . . . . . . . . .
Skilled nursing unit in AL . .
Independent/Assisted Living
Correctional facility . . . . . .
Group home . . . . . . . . . .
Other – Specify

Number and street

7. Have a seasonal or
second home?
1

C1. Is that place a house or
apartment or another type of
place like those shown on the
list I gave you?

DK/REF

F2. During 2008, when did you/he/she live or stay at
that place? Please provide as specific dates as possible.
FROM

TO

mm / dd / 2008

mm / dd / 2008

G2. (Ask or verify) Did you/he/she move or go back
and forth between places?
1
Move – Was
the move
1
Before 10/1 2
On 10/1 3
After 10/1
2
Back and forth
H2. (Ask or verify) During 2008, did you/he/she stay at that place:
Mark (X) all that apply.
5
Daytime only,
1
Most of the time?
didn’t spend nights?
Half of the time?
2
Certain days of the week?
Less than half the time? 6
3
4
Short stays?
Tu
W
M
Su
Th
F
Sa
I2. (Ask or verify) Were you/Was he/she there on
Wednesday, October 1st?
1

Yes

2

No

3

DK/REF

8

Section C – PERSON QUESTIONS – Continued
9. Please look at the list again.
Even if you/he/she did not live
there, did you/he/she spend even
one night in any of those types of
places around October 1st?
1
2
3

9a. What is the name and address of
that place?
Name

Number and street

Yes – Go to 9a
No
Go to 10
DK/REF

}

Apt/Unit #
City
ZIP Code

State

1

DK/REF – Probe for street, city, state.

9b. What are the landmarks or cross
streets closest to that place?

CL

OE

10. Miscellaneous questions

1

14

DK/REF

10a. (Ask or verify) What is your name
and phone number?
Same as previous
respondent – Go to next section
First name

Last name

)

–

Number and street
1

State

2
ZIP Code

3

6

7

2
3

Complete
Complete (Valid skip)
Complete (Unknown to
respondents)

FORM DX-1301 (7-24-2009)

4
5
6

Partial
Refusal
Other

CREW LEADER ASSESSMENT
Knowledgeable Respondent found and interview Complete/Partial
Case closed – 3 Knowledgeable Respondents found, no interview conducted
2
Case closed – unable to locate 3 Knowledgeable Respondents
3
1

CL

OE

TO

mm / dd / 2008

1
2
3

Yes
No
DK/REF

Notes

CL

Which one of the following best
describes the respondent?
Respondent is

4

Respondent’s name is on front
cover of form
Respondent lives at address on front of
form, but his/her name is not on cover
Relative/Caregiver
Neighbor
Landlord (superintendent, rental office,
owner, etc. for places with fewer than
10 units)
Other – Specify
Other – Specify

mm / dd / 2008

9e. (Ask or verify) Were you/Was he/she there on
Wednesday, October 1st?

Apt/Unit #

5

1

FROM

10b. (Ask or verify) What is your address? 10c. DO NOT ASK

4

FINAL PERSON-LEVEL OUTCOME CODE

9d. During 2008, when did you/he/she stay at that
place? Please provide as specific dates as possible.

DK/REF

City

Telephone (Area code)

(

9c. What type of place was it?
College housing
1
Dormitory or residence hall
Sorority/Fraternity house
2
Military housing
3
Military barracks
Military ship
4
Other group facilities
5
Nursing home
6
A 24-hour skilled nursing care unit within an assisted living facility
7
Independent or assisted living facility
Correctional facility
8
Group home
9
Emergency shelter
10
Residential school for people with disabilities
11
Psychiatric hospital
12
13
Other – Specify

OE

Notes

Section D – APRIL 1 OCCUPANCY

9

To be completed by the Interviewer

PI Household

Census Household

DO NOT READ THIS TO RESPONDENT
Two earlier interviews have reported two different households living at this address. Based on what you have
learned, what do you think the true situation is? Mark (X) as many boxes as you think apply AND write detailed
notes in the NOTES section.

NOTES

1
2

PI household is unknown
Census household is unknown

3

Only PI household lived at
on October 1, 2008

4

Only Census household lived at
on October 1, 2008

5

Neither household listed above lived at
on October 1, 2008

6

Both PI and Census households lived at
in separate housing units (i.e., different living spaces with separate entrances) on October 1, 2008

7

Both PI and Census households lived at
and shared a housing unit (i.e., shared living space) on October 1, 2008
Other – Explain in NOTES section

8

CL
FORM DX-1301 (7-24-2009)

OE

10

Section E – GEOCODING
Notes

1. On Tuesday, October 1, 2008, was there a housing unit at
?
1
2

Yes – Go to 2
No – Explain
CL

OE

2. DO NOT ASK:
Is
1
2

located in block

Yes – Go to 3
No – Specify the state, county, and block number for this address.
State

County

Block

CL

3. What is your name?
Last name

First name

4. What is your phone number?
Number

Area code

–

–

5. DO NOT ASK: Indicate outcome of this section.
1
2

Completed section with household member
Completed section with nonhousehold member
Nonhousehold member was:
1
2
3
4

3
4

?

Relative/Caregiver
Neighbor
Landlord (Superintendent, rental office, owner, etc.)
Other – Specify

Noninterview – Refusal
Noninterview – Other – Specify

FORM DX-1301 (7-24-2009)

OE

11

RECORD OF VISITS
Line
No.

Date
(a)

Month Day

Time

Attempt type

Visit
outcome

Comments

(b)

(c)

(d)

(e)

1

1

a.m. 2
p.m.
1

2

a.m. 2
p.m.
1

3

a.m. 2
p.m.
1

4

a.m. 2
p.m.
1

5

a.m. 2
p.m.
1

6

a.m. 2
p.m.
1

7

a.m. 2
p.m.
1

8

a.m. 2
p.m.
1

9

a.m. 2
p.m.
1

10

a.m. 2
p.m.

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1

Personal visit
Telephone

1

2
3

2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Personal visit
Telephone

1
2
3

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

Complete
Partial
No one home

4

5
6

5
6

5
6

5
6

5
6

5
6

5
6

5
6

5
6

5
6

Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other
Refusal
Callback
Other

CERTIFICATION
I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.
Interviewer
signature
Crew Leader
signature
FORM DX-1301 (7-24-2009)

FR code
Month

M M

Day

D D

FR code
Month

M M

Day

D D

Final outcome
201
203
216
218
219

Complete
Partial
No one home
Refusal
Other

Respondent classification
1
2
3

Non-proxy (single respondent)
Proxy (single respondent)
Multiple respondents

In what language
was most of the
interview
conducted?
1
2

CL/QI
initials

3

English
Spanish
Other – Specify

QA USE ONLY
1
2
3
4
5
6
7

Not eligible
Not selected
Selected
Pass
Fail (Includes No and DK fails)
Noninterview–Unresolved
Noninterview–Refused

NOTES

FORM DX-1301 (7-24-2009)

12