D-1 X11 2010 Experimental Questionnaire Version 11 (Race and His

Draft 3 (3-6-2009)

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U.S. DEPARTMENT OF COMMERCE

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

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.

Last Name

First Name

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

Use a blue or black pen.

MI

a 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
Age on April 1, 2010

Sex
Male
Female

Person 8

Sex

Last Name

Age on April 1, 2010

Male
Female

Person 9

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Sex

Date of Birth
Month
Day

Related to Person 1?
Year

• 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

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

Last Name

Age on April 1, 2010

Male

First Name

Date of Birth
Day
Month

MI

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

MI

Last Name
MI

First Name

6. What is Person 1’s sex? Mark I
J ONE box.
K
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.
Day
Year of birth
Month
Age on April 1, 2010

➜ 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

1. How many people were living or staying in this house,
apartment, or mobile home on April 1, 2010?

Age on April 1, 2010

Sex
Male

Date of Birth
Month
Day

Year

Female

Person 11

Yes
No

Last Name

First Name

2. Were there any additional people staying here
April 1, 2010 that you did not include in Question 1?
Mark I
J
K all that apply.
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

MI

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.
Sex

Age on April 1, 2010

Male

Date of Birth
Month
Day

Related to Person 1?
Year

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

3. Is this house, apartment, or mobile home —
Mark I
J
K ONE box.

No

Female

Person 12

Last Name

Sex

Age on April 1, 2010

Male

First Name

Date of Birth
Month
Day

¿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 d¼as a la semana. La llamada telefónica
es gratis.

MI

Year

Female

Yes
No

JIC1

4. What is your telephone number? We may call if we

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

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

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

Some other race — Print race. C

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.

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?

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?

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

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?

JIC2

–

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

§p."¤
791301

Form D-1(X11) (3-5-2009)

D-1(X11)

(3-6-2009)

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

USCENSUSBUREAU

D-1(X11) - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
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D-1(X11) - Base prints in BLACK

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Person 10

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

Date of Birth
Month
Day

U.S. CENSUS BUREAU

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Person 7

Economics and Statistics Administration

1. Print name of

Person 2

1. Print name of

Last Name
First 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

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

Last Name

First Name

MI

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

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

Female

1. Print name of Person 5

1. Print name of Person 4

First Name

MI

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

Last Name

Last 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

1. Print name of Person 6

Female

First Name

First Name

MI

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

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

§p.#¤
791302

MI

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

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

Female

Male

Female

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

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

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

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

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

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Year of birth
Age on April 1, 2010
Month
Day

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 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

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Person 3

Last Name

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

Male

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6. What is this person’s race? Mark I
J
Kone or more 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
Month
Day
Year of birth

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 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
Kone or more 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
Month
Day
Year of birth

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 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
Kone or more 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
Month
Day
Year of birth

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 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
Kone or more 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
Month
Day
Year of birth

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 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
Kone or more boxes.

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

White — For example, German, Irish, Lebanese, Egyptian, and so on.
Black, African Am., or Negro — For example, African American, Haitian,
Nigerian, and so on.
American Indian or Alaska Native — Print name of enrolled or principal tribe,
for example, Navajo, Mayan, Tlingit, and so on. C

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

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

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

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

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

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

Some other race — Print race. C

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

Some other race — Print race. C

➜ If more people were counted in Question 1 on the front

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

page, continue with Person 4.

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

Some other race — Print race. C

➜ If more people were counted in Question 1 on the front

➜ If more than six people were counted in Question 1 on

page, continue with Person 6.

the front page, turn the page and continue.
Form D-1(X11) (3-6-2009)

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D-1(X11) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
D-1(X11) - Base prints BLACK

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Draft 3 (3-6-2009)