D-1 X8 2010 Experimental Questionnaire Version 8 (Hispanic Orig

Generic Clearance for 2010 Census Program for Evaluations & Experiments (CPEX)

D-1(X8)_1_6_D5_041509

201 Census Alternative Questionnaire Experiment

OMB: 0607-0952

Document [pdf]
Download: pdf | pdf
Draft 5 (4-15-2009)

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U.S. DEPARTMENT OF COMMERCE

Use this section to complete information for the rest of the people you counted in Question 1 on the
front page. We may call for additional information about them.

Age on April 1, 2010

Sex

Sex

Age on April 1, 2010

MI

Day

Year

Day

Related to Person 1?
Year

• Do not count anyone living away either at college or in the
Armed Forces.
• Do not count anyone in a nursing home, jail, prison,
detention facility, etc., on April 1, 2010.
• Leave these people off your form, even if they will return to
live here after they leave college, the nursing home, the
military, jail, etc. Otherwise, they may be counted twice.

Yes
No

Person 9

Last Name

Sex

Age on April 1, 2010

First Name

MI

Date of Birth
Month

Male

Day

The Census must also include people without a permanent
place to stay, so:

Related to Person 1?
Year

Female

Yes

• If someone who has no permanent place to stay is staying
here on April 1, 2010, count that person. Otherwise, he or
she may be missed in the census.

No

Last Name

First Name

1. How many people were living or staying in this house,

MI

Last Name
MI

First Name

6. What is Person 1’s sex? Mark I
J
K ONE box.
Male

Female

7. What is Person 1’s age and what is Person 1’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

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 8 about Hispanic origin and
Question 9 about race. For this census, Hispanic origins are not races.
8. Is Person 1 of Hispanic, Latino, or Spanish origin? Mark I
J
K one or
more boxes.
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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

apartment, or mobile home on April 1, 2010?
Age on April 1, 2010

Sex

Month

Male

Day

Year

Female

Person 11

Sex

Age on April 1, 2010

First Name

Day

Sex

Age on April 1, 2010

Male

First Name

Day

Female

Yes
No

JIC1

Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

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

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

Some other race — Print race. C

4. What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–

Respondents are not required to respond to any information collection unless it displays a valid approval
number from the Office of Management and Budget.

FOR OFFICIAL USE ONLY

Thank you for completing your official
2010 Census form.

Mark I
J
K ONE box.

The U.S. Census Bureau estimates that, for the average household, this form will take about 10 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.

Related to Person 1?
Year

3. Is this house, apartment, or mobile home —

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al
1-866-943-2010 entre las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La llamada telefónica
es gratis.

MI

Date of Birth
Month

Children, such as newborn babies or foster children
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in baby sitters
People staying here temporarily
No additional people

TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

Yes
No

Female

Last Name

April 1, 2010 that you did not include in Question 1?
Mark I
J
K all that apply.

If you need help completing this form, call 1-866-948-2010 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.

Related to Person 1?
Year

9. What is Person 1’s race? Mark I
J
K one or more boxes.

2. Were there any additional people staying here

MI

Date of Birth
Month

Male

Person 12

Yes
No

Last Name

Number of people =

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

Related to Person 1?

Date of Birth

JIC2

–

OMB No. XXXX-XXXX-X: Approval Expires XX/XX/XXXX
Form

§p+"¤
791001
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D-1(X8)

(4-15-2009)

➜ If more people were counted in Question 1, continue with Person 2.

USCENSUSBUREAU

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D-1(X8) - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
D-1(X8) - Base prints in BLACK

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Person 10

• Count all people, including babies, who live and sleep here
most of the time.
The Census Bureau also conducts counts in institutions
and other places, so:

MI

Date of Birth
Month

The Census must count every person living in the United
States on April 1, 2010.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.

Yes
No

First Name

person living here who owns or rents this house, apartment, or mobile
home. If the owner or renter lives somewhere else, start with any adult
living here. This will be Person 1.
What is Person 1’s name? Print name below.

Start here

Related to Person 1?

Date of Birth

Last Name

Male
Female

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First Name

Month

Male
Female

Person 8

5. Please provide information for each person living here. Start with a

Use a blue or black pen.
Last Name

U.S. CENSUS BUREAU

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Person 7

Economics and Statistics Administration

This is the official form for all the people at this address.
It is quick and easy, and your answers are protected by law.

1. Print name of

Person 2

1.

Print name of

Person 3

1.

MI

First Name

J
K ONE box.
2. How is this person related to Person 1? Mark I
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

First Name

J
K ONE box.
3. What is this person’s sex? Mark I

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Male

Age on April 1, 2010

Month

Day

Year of birth

1.

MI

2. How is this person related to Person 1? 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

Female

Male

Print name of

Person 5

1.

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

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6. What is this person’s race? Mark I
J
K one or more boxes.

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

Female

Male

4. What is this person’s age and what is this person’s date of birth?

Female

4. What is this person’s age and 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.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.

Age on April 1, 2010

Age on April 1, 2010

Age on April 1, 2010

Age on April 1, 2010

Month

Day

Year of birth

more boxes.

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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

3. What is this person’s sex? Mark I
J
K ONE box.

Month

Day

Year of birth

Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.
Question 6 about race. For this census, Hispanic origins are not races.
Question 6 about race. For this census, Hispanic origins are not races.
Question 6 about race. For this census, Hispanic origins are not races.
5. Is this person of Hispanic, Latino, or Spanish origin? Mark I
J
K one or 5. Is this person of Hispanic, Latino, or Spanish origin? Mark I
J
K one or
J
K one or 5. Is this person of Hispanic, Latino, or Spanish origin? Mark I
J
K one or 5. Is this person of Hispanic, Latino, or Spanish origin? Mark I
more boxes.

§p+#¤
791002

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.

3. What is this person’s sex? Mark I
J
K ONE box.
Male

Person 6

First Name

2. How is this person related to Person 1? Mark I
J
K ONE box.

Female

4. What is this person’s age and what is this person’s date of birth?

Print name of
Last Name

First Name

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

3. What is this person’s sex? Mark I
J
K ONE box.

4. What is this person’s age and 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.

Person 4

First Name

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

3. What is this person’s sex? Mark I
J
K ONE box.

Female

4. What is this person’s age and what is this person’s date of birth?

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.

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

Print name of
Last Name

Last Name

Last Name

Male

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6. What is this person’s race? Mark I
J
K one or more boxes.

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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s race? Mark I
J
K one or more boxes.

Year of birth

NOTE: Please answer BOTH Question 5 about Hispanic origin and
Question 6 about race. For this census, Hispanic origins are not races.

more boxes.

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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s race? Mark I
J
K one or more boxes.

Day

5. Is this person of Hispanic, Latino, or Spanish origin? Mark I
J
K one or

more boxes.

more boxes.

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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

➜

Month

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 one or more origins, for
example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. What is this person’s 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

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

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, Cambodian, Hmong, Laotian,
Pakistani, Thai, and so on. C

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

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

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

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

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

Some other race — Print race. C

➜ If more people were counted in Question 1 on the
front page, continue with Person 3.

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

Some other race — Print race. C

➜

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

Some other race — Print race. C

➜

If more people were counted in Question 1 on the
front page, continue with Person 4.

If more people were counted in Question 1 on the
front page, continue with Person 5.

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

Some other race — Print race. C

➜

➜ If more people
live here, turn
the page and
continue.

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

Some other race — Print race. C

➜

If more people were counted in Question 1 on the
front page, continue with Person 6.

If more than six people were counted in Question 1
on the front page, turn the page and continue.
Form D-1(X8) (4-15-2009)

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D-1(X8) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
D-1(X8) - Base prints BLACK

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Draft 5 (4-15-2009)


File Typeapplication/pdf
File TitleD-1(X8)_1_1.g
File Modified2009-04-15
File Created2009-04-15

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