Download:
pdf |
pdf➤
➤
9"
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
GROUP QUARTERS
VALIDATION
QUESTIONNAIRE
This listing contains confidential information, the release of which
is prohibited by Title 13, United States Code.
FORM
D-351(GQV)
(10-27-2008)
USCENSUSBUREAU
FRONT COVER Solid black ink and cyan (100%)
§1g"¤
167001
➤
➤
9"
Form D-351(GQV) (10-27-2008)
and
Apartments
Avenue
Black
Blue
Boulevard
Brown
Basement
Box
Brick
Building
Circle
County
Court
Downstairs
Drive
East
Expressway
Floor
Freeway
Front
Garage
Green
General Delivery
Highway Contract Route
House
Highway
Interstate Highway
Intersection
Lane
Left
Living Quarters
Lower
&
Apts
Ave
Blk
Bl
Blvd
Brn
Bsmt
Box
Brk
Bldg
Cir
Co
Ct
Dwnstr
Dr
E
Expwy
Fl
Fwy
Frnt
Grg
Gr
Gen Del
HCR
Hse
Hwy
IInt
Ln
L
LQs
Lwr
Migrant living quarters
Mile
North
Number
Office
Place
Porch
Post Office
Postal Service Center
Private Road
Road
Railroad/Rural Route
Right
Route
South
School
Split level
Star Route
Street/State
Suite
Terrace
Trail
Trailer (Mobile Home)
Upper
Vacant
Vehicular Trail
Vacant Storage
West
White
Yellow
Mig LQs
Mi
N
#
Ofc
Pl
Prch
PO
PSC
PrRd
Rd
RR
R
RT
S
Schl
SL
SR
St
Ste
Ter
Trl
Trlr
Uppr
V
Ve Tr
VS
W
Wht
Ylw
§1g#¤
167002
FRONT COVER INSIDE SOLID BLACK INK
Draft 18 (10-27-2008)
OMB No. 0607-0919-C: Approval Expires 12/31/2011
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
GROUP QUARTERS VALIDATION QUESTIONNAIRE
MANAGEMENT ATTENTION
(For use by manager only)
Living Quarters Screener
1.
Is this address in the block
listed on the label or the
address listing page?
Yes ➞ Go to Question 2
APPLY ADDRESS LABEL HERE.
If the case is an Add – Apply Processing ID label here.
No ➞ Go to the Certification Tab
and mark (X) the "D1" box
in the Address Status
section.
2.
INTRODUCTION
Hello. My name is (Your name). I’m from the U.S. Census Bureau. (Show your
identification badge.) I’d like to speak with someone who knows where people live,
could live, or stay at this address or about the people that use the services provided
here. Would that be you, or should I speak with someone else? (Continue or re-read
introduction if referred to another respondent.)
We are updating our list of addresses as an important part of the 2010 Census. This
will help ensure that the 2010 Census is as accurate as possible. We estimate that it
will take approximately 10 minutes to conduct this interview. This notice explains
that your answers are confidential. (Provide a copy of the Confidentiality Notice to
the respondent and allow time to read it.)
3.
What is your name?
4a. We have your address listed as (read the address on the label above). Is this correct?
Yes ➞ Go to Question 5
No ➞ Go to Question 4b and make corrections on the next page.
Address Register
Line No.
FORM
D-351(GQV)
(10-27-2008)
USCENSUSBUREAU
D-351(GQV) Base Prints BLACK
Page No.
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
§1g$¤
167003
Page 4
FORM D-351(GQV) (10-27-2008)
4b. What is your correct address? (Complete for all added OLQs.)
House No.
Street Name
Unit Designation
ZIP Code
Building Name
Building No.
Rural Route ZIP Code
Rural Route Address
Physical Description/Location
(For ADDs only) Is this also your mailing address?
Yes
No
LCO
AA
State
County
Block
Map Spot
§1g%¤
167004
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 5
FORM D-351(GQV) (10-27-2008)
5. Now I am going to ask you some questions to help me determine what kind of place
this is. Is this a soup kitchen, a shelter for people experiencing homelessness, or a
facility that operates a regularly scheduled mobile food van?
Yes ➞ Go to Question 15
No ➞ Go to Question 6
6. Is this some type of facility, student housing, or group home?
Yes ➞ Go to Question 12
No ➞ Go to Question 7
7. Is this a hotel, motel, hostel, recreational vehicle (RV) park, campground,
carnival, marina, or racetrack?
Yes ➞ Go to Question 15
No ➞ Go to Question 8
8. Is this housing for people with a religious affiliation such as a convent, monastery,
or abbey?
Yes ➞ Go to Question 12
No ➞ Go to Question 9
9. Is this housing for workers, such as construction, migratory or farm workers, or for
students at Job Corps centers?
Yes ➞ Go to Question 12
No ➞ Go to Question 10
10. Is this a private residence?
Yes ➞ Go to Question 11
No ➞ Go to Question 12
11. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Housing Unit" box in the Address
Status section.
12. Does anyone live or stay here?
Yes ➞ Go to Question 15
No ➞ Go to Question 13
13. Could anyone live or stay here?
Yes ➞ Go to Question 15
No ➞ Go to Question 14
14. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Nonresidential" box in the Address
Status section.
15. What is the telephone number here?
–
–
16. Let me repeat the telephone number I just wrote down. (Read telephone number
given in Question 15 above.) Is that correct?
Yes ➞ Go to Question 17
No ➞ What is the correct telephone number?
–
–
➞ Go to Question 17
17. What is your job title?
§1g&¤
167005
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 6
FORM D-351(GQV) (10-27-2008)
18a. Next, I am going to show you a list. (Show respondent flashcard Side 1.) Which of
these BEST describes this place? Mark (X) one box.
1. Boarding school (except for schools for people with disabilities) ➞ Go to Question 18b
2. Correctional facility for adults or juveniles ➞ Go to Question 19
3. Fraternity or sorority house for students at a college, university, or seminary ➞ Go to Question 28
4. Group home (non-correctional) or residential treatment center (non-correctional) ➞ Go to
Question 21
5. Health care facility (e.g., skilled nursing facility, nursing facility, hospital, hospice) ➞ Go to
Question 24
6. Hotel, motel, hostel, single room occupancy units, inn, resort, lodge, or bed & breakfast ➞ Go
to Tab 7
7. Independent or assisted living facility ➞ Go to Tab 1
8. Military Quarters (e.g., barrack/dormitory, disciplinary barrack/jail, military treatment
facility) ➞ Go to Tab 15
9. Recreational vehicle (RV) park, campground, carnival, marina, or racetrack ➞ Go to Tab 10
10. Religious group living quarters intended to house members living in a group situation (e.g.,
convent, monastery, or abbey) [Type Code 902] ➞ Go to Tab 3
11. Residence hall or dormitory for students that is owned, leased, or managed either by a college,
university, or seminary, or by a private entity or organization [Type Code 501] ➞ Go to Tab 2
12. Schools for people with disabilities (e.g., schools for the physically or developmentally
disabled) [Type Code 405] ➞ Go to Tab 11
13. Soup kitchen, shelter for people experiencing homelessness, or a facility that operates a
regularly scheduled mobile food van. ➞ Go to Question 25
14. Workers’ group living quarters or group housing at Job Corps centers (e.g., migratory farm
worker quarters, ranch housing, vocational training facilities, or housing for staff)
[Type Code 901] ➞ Go to Tab 8
15. Private residence – THIS ENDS OUR INTERVIEW. Thank you very much for
answering these questions. Go to the Certification Tab and mark (X) the
"Housing Unit" box in the Address Status section.
18b. At this address, is there housing for staff?
Yes ➞ Go to Question 18c
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box in
the Address Status section.
18c. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Tab 8
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box in
the Address Status section.
19. Is this correctional facility intended for adults or juveniles? Mark (X) one box.
Adults ➞ Go to Question 20
Juveniles [Type Code 203] ➞ Go to Tab 4
20. Now I am going to show you a list of types of correctional facilities. (Show respondent
flashcard Side 2.) Which of these BEST describes this correctional facility? Mark (X)
one box.
1. Federal detention center (also include Metropolitan detention center, Metropolitan
Correctional Center, Bureau of Indian Affairs detention center, Immigration and
Customs Enforcement Service Processing Centers and contract detention facilities)
[Type Code 101]
2. Federal prison [Type Code 102]
3. State prison [Type Code 103]
4. Local or county jail or a correctional facility operated by the American Indian and
Alaska Native (AIAN) tribal governments (also included are work farms and camps
holding people awaiting trial or serving short sentences) [Type Code 104]
5. Correctional residential facility (including a halfway house, restitution center,
prerelease center and work release center) [Type Code 105]
⎫
⎬
⎭
Go to
Tab 4
§1g’¤
167006
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 7
FORM D-351(GQV) (10-27-2008)
21. Which of the following BEST describes this facility?
Is this a . . . (read both) Mark (X) one box.
group home (non-correctional)? ➞ Go to Question 22
residential treatment center (non-correctional)? ➞ Go to Question 23
22. Is this group home intended for adults or juveniles? Mark (X) one box.
Adults [Type Code 801] ➞ Go to Tab 3
Juveniles [Type Code 201] ➞ Go to Tab 9
23. Is this residential treatment center intended for adults or juveniles? Mark (X) one box.
Adults [Type Code 802] ➞ Go to Tab 3
Juveniles [Type Code 202] ➞ Go to Tab 9
24. Which of the following BEST describes this facility?
Is this a . . . (read list) Mark (X) one box.
skilled nursing facility or nursing facility? [Type Code 301] ➞ Go to Tab 1
hospital including mental or psychiatric hospital? ➞ Go to Tab 6
in-patient, free-standing hospice facility? [Type Code 403] ➞ Go to Tab 5
25. Is this facility a shelter?
Yes ➞ Go to Tab 12
No ➞ Go to Question 26
26. Is this facility a soup kitchen?
Yes [Type Code 702] ➞ Go to Tab 13
No ➞ Go to Question 27
27. Is this a facility that operates a regularly scheduled mobile food van?
Yes [Type Code 704] ➞ Go to Tab 14
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box
in the Address Status section.
28. Is this a fraternity or sorority house that is recognized by a college, university, or
seminary?
Yes [Type Code 501] ➞ Go to Tab 2
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Housing Unit" box in
the Address Status section.
§1g(¤
167007
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 8
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g)¤
167008
Page 9
FORM D-351(GQV) (10-27-2008)
SKILLED NURSING FACILITY, NURSING FACILITY, OR
INDEPENDENT OR ASSISTED LIVING FACILITY
1
1. What is the full name of this facility?
2. Next, I have some questions about the building at the address we just verified.
At this address is there . . . (Read each question below.)
a. a skilled nursing unit or a nursing unit?
b. housing for staff?
c. independent or assisted living units?
Yes
Yes
Yes
No
No
No
3. Is EITHER Question 2a OR 2b above marked "Yes?"
Yes ➞ Go to Question 4
No ➞ Go to Question 17
4. Is the answer to Question 2a above "Yes" for skilled nursing unit or nursing unit?
Yes [Type Code 301] ➞ Go to Question 5
No ➞ Go to Question 7
5. Is the name of this skilled nursing unit or nursing unit exactly the same as the facility
name?
Yes
No ➞ Specify
6. What is the maximum number of residents who can live or stay here in the skilled
nursing unit or nursing unit at this address?
Maximum number of residents
7. Is the answer to Question 2b above "Yes" for housing for staff?
Yes ➞ Go to Question 8
No ➞ Go to Question 10
8. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 9
No ➞ Go to Question 10
9. What is the maximum number of staff who can live at this address?
Maximum number of staff
10. Is the answer to Question 2c above "Yes" for independent or assisted living units?
Yes ➞ Go to Question 11
No ➞ Go to Question 16
11. Do you have additional Questionnaires or a D-322(GQV) Multiple Questionnaires List
for this address?
Yes ➞ Go to Question 12
No ➞ Go to Question 15
§1g*¤
167009
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 10
FORM D-351(GQV) (10-23-2008)
12. Now I’d like to read a list of addresses and ask you to tell me whether they are
independent or assisted living units here at this address. (Read addresses from
Questionnaires/list and mark each address confirmed as a HU, then go to Question 13.)
13. Other than the addresses we just talked about, are there any other independent or
assisted living units at this address?
Yes ➞ Go to Question 14
No ➞ Go to Question 16
14. What are the addresses of all these other independent or assisted living units
at this address? Go to the HU listing tab and list each of these units, then go to
Question 16.
15. Earlier you mentioned there are independent or assisted living units at this address.
What are the addresses of all these independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 16.
16. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
For facility with ONLY independent or assisted living units
17. Do you have additional Questionnaires or a D-322(GQV) Multiple Questionnaires List
for this address?
Yes ➞ Go to Question 18
No ➞ Go to Question 21
18. Now I’d like to read a list of addresses and ask you if they are independent or assisted
living units here at this address. (Read addresses from Questionnaires/list and mark
each unit identified as a HU, then go to Question 19.)
19. Other than the addresses we just talked about, are there any other independent or
assisted living units at this address?
Yes ➞ Go to Question 20
No ➞ Go to Question 22
20. What are the addresses of all these other independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 22.
21. Earlier you mentioned there are independent or assisted living units at this address.
What are the addresses of all these independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 22.
22. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "D3" box in the Address Status section.
§1g+¤
167010
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 11
FORM D-351(GQV) (10-27-2008)
RESIDENCE HALL, DORMITORY, OR FRATERNITY/SORORITY HOUSE
FOR COLLEGE, UNIVERSITY, OR SEMINARY STUDENTS
1. What is the full name of this residence hall, dormitory, fraternity or sorority house?
2. What is the maximum number of people who can live or stay here at this address?
2
Maximum number of people
3. What is the name of this college, university, or seminary? (Enter all that apply.)
4. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1g,¤
167011
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 12
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g-¤
167012
Page 13
FORM D-351(GQV) (10-27-2008)
RELIGIOUS GROUP LIVING QUARTERS INTENDED TO HOUSE
MEMBERS LIVING IN A GROUP SITUATION, GROUP HOME
(non-correctional) FOR ADULTS, OR RESIDENTIAL TREATMENT
CENTER (non-correctional) FOR ADULTS
1. What is the full name of this facility?
2. Next, I have a question about the building at the address we just verified. What
is the maximum number of people who can live or stay here at this address?
Maximum number of people
3. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
3
§1g.¤
167013
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 14
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g/¤
167014
Page 15
FORM D-351(GQV) (10-27-2008)
CORRECTIONAL FACILITY FOR ADULTS OR JUVENILES
1. What is the full name of this correctional facility?
2. At this address, is there more than one building where inmates can live or stay?
Yes ➞ Go to Question 9
No ➞ Go to Question 3
3. Is the name of this building exactly the same as the facility name?
Yes
No ➞ Specify name of building
4. What is the maximum number of inmates who can live or stay here?
Maximum number of inmates
5. At this address, in addition to housing for inmates, is there also housing for staff?
Yes ➞ Go to Question 6
No ➞ Go to Question 8
6. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 7
No ➞ Go to Question 8
7. What is the maximum number of staff who can live at this address?
4
Maximum number of staff
8. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
9. How many buildings are there where inmates can live or stay?
Total number of buildings
10. Now I would like to ask you some questions about each of the buildings where
inmates can live or stay. List all buildings where inmates can live or stay. Ask
both Questions b and c for each building.
a.
Let’s
talk
about
the . . .
b.
What is the name or designation of
this building?
c.
What is the
maximum number
of inmates who can
live or stay here at
this building?
1st
building
➞ Go to Question 10a
and ask about
the 2nd building
Continue with Question 10 on the next page.
§1g0¤
167015
D-351(GQV) Base Prints BLACK (20% and 100%)
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 16
FORM D-351(GQV) (10-27-2008)
10. Continued
a. Let’s
b.
talk
about
the . . .
What is the name or designation of
this building?
c.
What is the
maximum number
of inmates who can
live or stay here at
this building?
2nd
building
Is there another
building?
3rd
building
Yes ➞ Go to
Question 10a
and ask about
the next building
4th
building
No ➞ Go to
Question 12
5th
building
6th
building
7th
building
8th
building
9th
building
10th
building
11th
building
12th
building
13th
building
11.
Mark (X) only if there are more buildings, go to D-351CF(GQV), Correctional Facility
Continuation Form, then come back to Question 12.
12. Check to make sure the number of buildings listed agrees with the number of buildings in
Question 9.
13. At this address, in addition to housing for inmates, is there also housing for staff?
Yes ➞ Go to Question 14
No ➞ Go to Question 16
14. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 15
No ➞ Go to Question 16
15. What is the maximum number of staff who can live at this address?
Maximum number of staff
16. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1g1¤
167016
D-351(GQV) Base Prints BLACK (20% and 100%)
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 17
FORM D-351(GQV) (10-27-2008)
IN-PATIENT HOSPICE FACILITY (Free-standing only)
1. What is the full name of this facility?
2. Next, I have some questions about the building at the address we just verified.
What is the maximum number of patients who can live or stay here at this
address?
Maximum number of patients
3. At this address, in addition to housing for patients, is there also housing for
staff?
Yes ➞ Go to Question 4
No ➞ Go to Question 6
4. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6
5. What is the maximum number of staff who can live at this address?
Maximum number of staff
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
5
§1g2¤
167017
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 18
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g3¤
167018
Page 19
FORM D-351(GQV) (10-27-2008)
HOSPITAL (including mental or psychiatric hospital)
1. What is the full name of this facility?
2. Is the name of this building exactly the same as the facility name?
Yes
No ➞ Specify name of building
3. Now I have some questions about the building at the address we just verified.
a. At this building . . . (Read each question below.)
(1) is there a mental or
psychiatric unit or floor for
long-term care?
(2) is there an in-patient
hospice unit?
(3) is there a skilled nursing
unit?
(4) do you accept patients
with no disposition or exit
plan?
b. (If "Yes" in Question 3a, ask):
What is the maximum
number of these
patients?
Type
code
Yes ➞ Go to 3b
No
401
Yes ➞ Go to 3b
No
403
Yes ➞ Go to 3b
No
301
Yes ➞ Go to 3b
No ➞ Go to
Question 4
402
4. At this building, is there housing for staff?
Yes ➞ Go to Question 5
No ➞ Go to Question 7
5. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 6
No ➞ Go to Question 7
6. What is the maximum number of staff who can live at this address?
Maximum number of staff
7. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview.
If Question 3a(1), 3a(2), 3a(3), 3a(4), or 5 is answered "Yes," go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
If Questions 3a(1), 3a(2), 3a(3), 3a(4), and 5 are all answered "No," go to the
Certification Tab and mark (X) the "Nonresidential" box in the Address Status
section.
§1g4¤
167019
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
6
Page 20
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g5¤
167020
Page 21
FORM D-351(GQV) (10-27-2008)
HOTEL, MOTEL, HOSTEL, SINGLE ROOM OCCUPANCY UNITS,
INN, RESORT, LODGE, OR BED & BREAKFAST
1. What is the full name of this facility?
2. Are all of the rooms or units at this building used ENTIRELY to house people
experiencing homelessness?
Yes [Type Code 701] ➞ Go to Question 3
No ➞ Go to Question 5
3. What is the maximum number of people experiencing homelessness who can
live or stay here?
Maximum number of people
4. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the
Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.
5. Will you be open during March or April?
Yes ➞ Go to Question 6
No ➞ Go to Question 9
6. What is the maximum number of rooms available for rent at this location?
Maximum number of rooms
7. Are there any rooms occupied by people who live or stay here most of the time?
Yes ➞ Go to Question 8
No ➞ Go to Question 9
8. How many rooms do you expect to be occupied by people who live or stay here
most of the time during March or April?
Number of rooms
9. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions. Go
to the Certification Tab and mark (X) the "Transient" box in the Address Status section.
§1g6¤
167021
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
7
Page 22
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g7¤
167022
Page 23
FORM D-351(GQV) (10-27-2008)
WORKERS’ GROUP LIVING QUARTERS OR
GROUP HOUSING AT JOB CORPS CENTERS
(e.g., migratory farm worker quarters, ranch housing, vocational
training facilities, or housing for staff)
1. What is the full name of this facility?
➞ Go to Question 2
No name ➞ Go to Question 3
2. Next, I have some questions about the building at the address we just verified. Is the
name of the building exactly the same as the facility name?
Yes ➞ Go to Question 4
No ➞ Specify name of building
Go to Question 4
3. Does this building have a name?
Yes ➞ Specify name of building
Go to Question 4
No ➞ Go to Question 4
4. What is the maximum number of people who can live or stay here at this address?
Maximum number of people
5. What months of the year do students or workers usually live or stay here?
Mark (X) all that apply.
All year
January
February
March
April
May
June
July
August
September
October
November
December
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1g8¤
167023
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
8
Page 24
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g9¤
167024
Page 25
FORM D-351(GQV) (10-27-2008)
GROUP HOME (non-correctional) FOR JUVENILES OR RESIDENTIAL
TREATMENT CENTER (non-correctional) FOR JUVENILES
1. What is the full name of this juvenile facility?
2. Next, I have some questions about the building at the address we just verified. What
is the maximum number of juveniles who can live or stay here at this address?
Maximum number of juveniles
3. At this address, in addition to housing for juveniles, is there also housing for
staff?
Yes ➞ Go to Question 4
No ➞ Go to Question 6
4. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6
9
5. What is the maximum number of staff who can live at this address?
Maximum number of staff
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1g:¤
167025
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 26
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g;¤
167026
Page 27
FORM D-351(GQV) (10-27-2008)
RECREATIONAL VEHICLE (RV) PARK, CAMPGROUND,
CARNIVAL, MARINA, OR RACETRACK
1. What is the full name of this facility?
2. What months of the year are you open? Mark (X) all that apply.
All year
January
February
March
April
May
June
July
August
September
October
November
December
3. What is the maximum number of sites, pads, slips, or units at this location?
Maximum number
4. How many sites, pads, slips, or units do you expect to be occupied during
March or April?
10
Number
5. Can we have a site map or plan of your grounds/facility/area that will indicate
the places where people can camp, park their recreational vehicles, or stay on
their boats?
Yes ➞ Collect the site plan, then go to Question 6
No ➞ Go to Question 6
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Transient" box in the Address Status
section.
§1g<¤
167027
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 28
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g=¤
167028
Page 29
FORM D-351(GQV) (10-27-2008)
SCHOOLS FOR PEOPLE WITH DISABILITIES
(e.g., schools for the physically or developmentally disabled)
1. What is the full name of this facility?
2. Next, I have some questions about the building at the address we just verified.
What is the maximum number of students who can live or stay here at this address?
Maximum number of students
3. At this address, in addition to housing for students, is there also housing for staff?
Yes ➞ Go to Question 4
No ➞ Go to Question 6
4. Is the housing for staff used as their usual residence?
Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6
5. What is the maximum number of staff who can live at this address?
Maximum number of staff
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
11
§1g>¤
167029
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 30
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1g?¤
167030
Page 31
FORM D-351(GQV) (10-27-2008)
SHELTER FOR PEOPLE EXPERIENCING HOMELESSNESS
(Emergency and Transitional) OR DOMESTIC VIOLENCE SHELTER
1. What is the full name of this shelter?
2. Is this facility a . . . (read both) Mark (X) one box.
shelter for people experiencing homelessness (emergency and transitional
shelter)? [Type Code 701]
domestic violence shelter? [Type Code 703]
3. What is the maximum number of people who can live or stay here?
Maximum number of people
4. In addition to providing housing, do you also operate a soup kitchen here for people
experiencing homelessness?
Yes [Type Code 702] ➞ Go to Question 5
No ➞ Go to Question 7
5. What is the full name of this soup kitchen?
6. What is the maximum number of people who can be served at a meal?
Maximum number of people
7. Do you also operate a regularly scheduled mobile food van?
Yes [Type Code 704] ➞ Go to Question 8
No ➞ Go to Question 9
8. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
Maximum number of people
9. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
12
§1g@¤
167031
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 32
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gA¤
167032
Page 33
FORM D-351(GQV) (10-27-2008)
SOUP KITCHEN
13
1. What is the full name of this soup kitchen?
2. What is the maximum number of people who can be served at a meal?
Maximum number of people
3. Do you also operate a regularly scheduled mobile food van?
Yes [Type Code 704] ➞ Go to Question 4
No ➞ Go to Question 5
4. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
Maximum number of people
5. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1gB¤
167033
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 34
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gC¤
167034
Page 35
FORM D-351(GQV) (10-27-2008)
REGULARLY SCHEDULED MOBILE FOOD VAN
1. What is the full name of this facility?
2. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
14
Maximum number of people
3. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Someone may contact you by telephone to verify this interview. Go to the Certification
Tab and mark (X) the "Group Quarters" box in the Address Status section.
§1gD¤
167035
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 36
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gE¤
167036
Page 37
FORM D-351(GQV) (10-27-2008)
MILITARY QUARTERS
(e.g., barrack/dormitory, disciplinary barrack/jail, Military Treatment Facility)
1. What is the full name of this military installation?
2. Is this building a . . . (read all) Mark (X) one box.
barrack/dormitory – non-disciplinary? [Type Code 601]
disciplinary barrack/jail? [Type Code 106]
Military Treatment Facility? ➞ Go to Question 4
3. What is the maximum number of people who can be assigned to this
barrack/dormitory/jail?
Maximum number of people ➞ Go to Question 5
4. Now I have some questions about this Military Treatment Facility.
a. At this facility . . . (Read each question below.)
(1) are there Active Duty
military personnel
assigned to a bed?
(2) do you accept patients
with no disposition or
exit plan?
b. (If "Yes" in Question 4a, ask):
What is the maximum
number of these
patients?
Yes ➞ Go to 4b
No
Type
code
404
Yes ➞ Go to 4b
No ➞ Go to
Question 6
402
5. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address
Status section.
6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
If question 4a(1) or 4a(2) is answered "Yes" – Go to the Certification Tab and mark (X) the
"Group Quarters" box in the Address Status section.
If questions 4a(1) and 4a(2) are answered "No" – Go to the Certification Tab and mark (X) the
"Nonresidential" box in the Address Status section.
§1gF¤
167037
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
15
Page 38
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gG¤
167038
Page 39
FORM D-351(GQV) (10-27-2008)
NOTES
For each note, enter the Page number in column (1) and the Question
number in column (2). Also enter the Note(s) on an INFO-COMM.
Page
number
Question
number
Note
(1)
(2)
(3)
NOTES
§1gH¤
167039
D-351(GQV) Base Prints BLACK and D351(GQV) Prints Pantone Process Cyan (100%)
Page 40
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gI¤
167040
Page 41
FORM D-351(GQV) (10-27-2008)
HU LISTING PAGE
UNIT DESIGNATION
PAGE
OF
Is the Unit already listed in the Address Register as a HU?
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
HU Listing Page
No
Yes ➞ Line No.
If there are more housing units, please continue on the next page.
§1gJ¤
167041
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 42
FORM D-351(GQV) (10-27-2008)
HU LISTING PAGE – Continued
UNIT DESIGNATION
PAGE
OF
Is the Unit already listed in the Address Register as a HU?
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
No
Yes ➞ Line No.
Page No.
Mark (X) if a Continuation Form is needed and then please continue with Housing Unit Continuation Form,
D-351HU(GQV).
§1gK¤
167042
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
Page 43
FORM D-351(GQV) (10-27-2008)
ADDRESS STATUS
Mark (X) the appropriate box below.
Group Quarters
Crew Leader Initials
Housing Unit
Nonresidential ➞ Describe location on an INFO-COMM
Crew Leader Initials
Vacant ➞ Describe location on an INFO-COMM
Transient
D1 – Cannot locate in listed block ➞ Describe location efforts on an INFO-COMM
Date verified
Mo
Day
Crew Leader Initials
Year
D2 – Information for this questionnaire was collected on:
Survivor Case ID No.
D3 ➞ Mark (X) only if directed to in Tab 1
CERTIFICATION
Sign and date the certification below.
I certify that the entries I have made on this questionnaire are correct to the best of my
knowledge.
Lister Name – Printed
Last name
First name
MI
Date
Mo
Lister Signature
Date
Mo
Supervisor Initials
Day
Day
2nd CALLBACK
Year
Date
Mo
Time
Day
Year
Time
1st REASSIGNMENT
a.m.
p.m.
•
•
2nd REASSIGNMENT
Date
Mo
Day
Year
Lister Name
Date
Mo
Day
Year
§1gL¤
167043
D-351(GQV) Base Prints BLACK
D351(GQV) Prints Pantone Process Cyan (25%, 50%, and 100%)
CERTIFICATION
a.m.
p.m.
•
•
Lister Name
Year
Year
1st CALLBACK
Date
Mo
Day
Page 44
FORM D-351(GQV) (10-27-2008)
This Page Intentionally Left Blank
§1gM¤
167044
| File Type | application/pdf |
| File Title | d351gqvcvrfront.g |
| File Modified | 2008-10-27 |
| File Created | 2008-10-27 |