Other Public Use Forms

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RECORD ANSWERS ON OFFICIAL CENSUS FORM ONLY.

ASSISTANCE GUIDE – LARGE PRINT
NOTE: DO NOT WRITE ON THESE PAGES.
Enter all responses on the OFFICIAL CENSUS
QUESTIONNAIRE. This guide provides a large print
text of the basic questions and answer categories for the
Census 2000 English Questionnaire.
U.S. Department of Commerce • Bureau of the Census

DC

Your Census 2000 English Questionnaire is
the official form for all the people at this
address. It is quick and easy, and your
answers are protected by law. Complete the
Census and help your community get what
it needs — today and in the future!

Start Here

Please use a black or blue pen.
1. How many people were living or staying in this house,
apartment, or mobile home on April 1, 2000?
Number of people
INCLUDE in this number:
• foster children, roomers, or housemates
• people staying here on April 1, 2000 who
have no other permanent place to stay
• people living here most of the time while working,
even if they have another place to live
DO NOT INCLUDE in this number:
• college students living away while attending college
• people in a correctional facility, nursing home, or
mental hospital on April 1, 2000
• Armed Forces personnel living somewhere else
• people who live or stay at another place most of
the time

IN

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Person 1 (continued)
2. Is this house, apartment, or mobile home —
Mark ✗ ONE box.
Owned by you or someone in this household
with a mortgage or loan?
Owned by you or someone in this household
free and clear (without a mortgage or loan)?
Rented for cash rent?
Occupied without payment of cash rent?
3. Please answer the following questions for each person
living in this house, apartment, or mobile home. Start
with the name of one of the people living here who owns,
is buying, or rents this house, apartment, or mobile home.
If there is no such person, start with any adult living or
staying here. We will refer to this person as Person 1.
What is this person’s name? Print name below.
Last Name
First Name

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4. What is Person 1’s telephone number? We may call this
person if we don’t understand an answer.
Area Code + Number

IN

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5. What is Person 1’s sex? Mark ✗ ONE box.
Male
Female
6. What is Person 1’s age and what is Person 1’s date of birth?
Print numbers in boxes.
Age on April 1, 2000
Month Day
Year of birth
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Person 1 (continued)
➔ NOTE: Please answer BOTH Questions 7 and 8.
7. Is Person 1 Spanish/Hispanic/Latino? Mark ✗ the
"No" box if not Spanish/Hispanic/Latino.
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican Am.,
Yes, Cuban
Chicano
Yes, other Spanish/Hispanic/Latino – Print group.

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8. What is Person 1’s race? Mark ✗ one or more races to
indicate what this person considers himself/herself to be.
White
Black, African Am., or Negro
American Indian or Alaska Native – Print name of
enrolled or principal tribe.

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Japanese
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Korean

Asian Indian
Chinese
Vietnamese
Filipino
Other Asian – Print race.

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Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander –
Print race.

Some other race – Print race.
➔ If more people live here, continue with Person 2.

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Persons 2 – 6

RECORD ANSWERS ON OFFICIAL CENSUS FORM ONLY.

1. What is this person’s name? Print name below.
Last Name
First Name

MI

2. How is this person related to Person 1? Mark ✗ ONE box.
If NOT RELATED to Person 1:
Husband/wife
Natural-born son/daughter Roomer, boarder
Housemate, roommate
Adopted son/daughter
Unmarried partner
Stepson/stepdaughter
Foster child
Brother/sister
Other nonrelative
Father/mother
Grandchild
Parent-in-law
Son-in-law/daughter-in-law
Other relative – Print
exact relationship

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3. What is this person’s sex? Mark ✗ ONE box.
Male
Female
4. What is this person’s age and what is this
person’s date of birth?
Print numbers in boxes.
Age on April 1, 2000
Month Day
Year of birth

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Persons 2 – 6 (continued)
➔ NOTE: Please answer BOTH Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino? Mark ✗ the
"No" box if not Spanish/Hispanic/Latino.
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican Am.,
Yes, Cuban
Chicano
Yes, other Spanish/Hispanic/Latino – Print group.

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N

6. What is this person’s race? Mark ✗ one or more races to
indicate what this person considers himself/herself to be.
White
Black, African Am., or Negro
American Indian or Alaska Native – Print name of
enrolled or principal tribe.

M

R
Japanese
O
Korean

Asian Indian
Chinese
Vietnamese
Filipino
Other Asian – Print race.

IN

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F

A

T

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Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander –
Print race.

Some other race – Print race.
➔ If more people live here, continue with the next person.

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RECORD ANSWERS ON OFFICIAL CENSUS FORM ONLY.

Persons 7 – 12
If you didn’t have room to list everyone who lives
in this house or apartment, please list the others
below. You may be contacted by the Census Bureau
for the same information about these people.
Person 7 – Last Name
First Name

MI

Person 8 – Last Name
First Name

MI

Person 9 – Last Name

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First Name

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Person 10 – Last Name
First Name

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Person 11 – Last Name
First Name

MI

MI

Person 12 – Last Name
First Name

MI

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The 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. Comments about the
estimate should be directed to the Associate
Director for Finance and Administration,
Attn: Paperwork Reduction Project 0607-0856,
Room 3104, Federal Building 3, Bureau of the
Census, Washington, DC 20233.

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

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Thank
O you for
F
completing
your official
IN Census 2000 form.
U.S.

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If you need help completing your Census 2000 form,
call 1–800–471–9424 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.
TDD – Telephone display device for the hearing
impaired. Call 1–800–582–8330 between 8:00 a.m. and
9:00 p.m., 7 days a week. The telephone call is free.
¿NECESITA AYUDA? Si usted necesita ayuda para
completar este cuestionario llame al 1–800–471–8642
entre las 8:00 a.m. y las 9:00 p.m., 7 días a la semana.
La llamada telefónica es gratis.

IN

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