D-1 X17 2010 Experimental Questionnaire Version 17 (Race)

Draft 1 (3-10-2009)

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U.S. DEPARTMENT OF COMMERCE

Last Name

First Name

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

Use a blue or black pen.

MI

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
Sex

Age on April 1, 2010

Month

Male
Female

Person 8

Last Name

Age on April 1, 2010

Sex

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Year

Last Name

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

First Name

MI

Date of Birth
Month

Male

Day

Related to Person 1?
Year

Female

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

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
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 and Question 9.
8. Is Person 1 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

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

Sex

Age on April 1, 2010

Month

Male

Related to Person 1?

Date of Birth
Day

Year

Female

Person 11

Yes
No

First Name

Last 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

Month

Male

Related to Person 1?

Date of Birth
Day

Year

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

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

First Name

Day

Year

Female

Thank you for completing your official
2010 Census form.

Yes
No

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
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?

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?

Date of Birth
Month

¿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

9. Is Person 1... Mark I
J
K one or more boxes.

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

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

Asian

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

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

Some other race — Print below. C

–

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

JIC2

Form

§p="¤
792801
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D-1(X17)

(3-10-2009)

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

USCENSUSBUREAU

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D-1(X17) - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
D-1(X17) - 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
Day

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

No

Age on April 1, 2010

Sex

Day

Related to Person 1?

First Name

Month

Male
Female

Person 9

Date of Birth

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.

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.

1. Print name of Person 2

1. Print name of Person 3

Last Name

MI

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

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
Female

Age on April 1, 2010

Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Question 5 and Question 6.
5. Is this person 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
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Last Name

6. Is this person... Mark I
J
K one or more boxes.
White
Black or African Am.
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

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

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

Some other race — Print below. C

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

First Name

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

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

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

1. Print name of Person 5

1. Print name of Person 4

Last Name

First Name

Male

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Female

Age on April 1, 2010

First Name

Print numbers in boxes.
Month
Day
Year of birth

First Name

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
Male

Last Name

Last Name

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

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

Female

Age on April 1, 2010

Male
Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Question 5 and Question 6.

➜ NOTE: Please answer BOTH Question 5 and Question 6.

➜

5. Is this person of Hispanic, Latino, or Spanish origin?

5. Is this person of Hispanic, Latino, or Spanish origin?

5. Is this person of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

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

Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. Is this person... Mark I
J
K one or more boxes.

6. Is this person... Mark I
J
K one or more boxes.

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

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

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

Some other race — Print below. C

continue with Person 4.

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

Female

4. What is this person’s date of birth and what is this person’s age?
Age on April 1, 2010

Print numbers in boxes.
Month
Day
Year of birth

➜ NOTE: Please answer BOTH Question 5 and Question 6.

NOTE: Please answer BOTH Question 5 and Question 6.

5. Is this person 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

6. Is this person... 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 origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

6. Is this person... Mark I
J
K one or more boxes.

White
Black or African Am.

White
Black or African Am.

White
Black or African Am.

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

American Indian or Alaska Native — Print name of enrolled or principal tribe. C

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

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

Some other race — Print below. C

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

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

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

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

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792802

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

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

Print numbers in boxes.
Month
Day
Year of birth

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.

Female

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

First Name

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

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

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

1. Print name of Person 6

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

Some other race — Print below. C

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

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

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

Some other race — Print below. 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(X17) (3-10-2009)

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D-1(X17) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
D-1(X17) - Base prints BLACK

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Draft 1 (3-10-2009)