D-61 (SCR) Informational Copy of Shipboard Census Report

Draft 1 (10-16-2008)

OMB No. 0607-0919-C: Approval Expires 12/31/2011

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Shipboard Census Report
Use a blue or black pen.

Start here
1. What is your name? Print name below.

6. What is the name of the ship to which you are
assigned?

Last Name
MI

First Name

7. What is the name of the operator of this ship?

2. What is your sex? Mark I
J
K ONE box.

If U.S. Government operator, specify Navy, Coast Guard, etc.

C

O

PY

Female
Male
3. What is your age and what is your 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
Year of birth
Month
Day

8. Do you have a house, apartment, or mobile home
where you usually stay when off duty?

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and

L

Yes ➜Go to Question 9 on the back.
No, I live on this ship. ➜This completes the form.

N

M

5. What is your race? Mark I
J
K one or more boxes.

A

TI

O

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

A

Question 5 about race. For this census, Hispanic origins are not races.
4. Are you of Hispanic, Latino, or Spanish origin?

FO

R

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

IN

Japanese
Asian Indian
Korean
Chinese
Vietnamese
Filipino
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, 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
Form D-61(SCR) (10-16-2008)

USCENSUSBUREAU

D-61(SCR) - Base Black ink

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D-61(SCR) - Tone Pantone Process Cyan - 10%, 25%, and 50%

Draft 1 (10-16-2008)

9. (If Yes) What is the full address of the place where you
live or stay MOST OF THE TIME?
Please complete all that apply.

The U.S. Census Bureau estimates that, for the average
respondent, this form will take about 5 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.

Street address number

Street name

PY

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

O

Apartment number

A

L

C

Rural route address

FOR OFFICIAL USE ONLY

N

City

O

GQ Control Number

TI

County

M

A

State or foreign country

A. PN

B. JIC1

C. JIC2

IN

FO

R

ZIP Code

Thank you for completing your official 2010 Census form.

§2|#¤

FORM D-61(SCR) (10-16-2008)

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D-61(SCR) - Base Black ink

D-61(SCR) - Tone Pantone Process Cyan - 10%, 25%, and 50%