D-1 R1 2010 Census Quality Survey (DRAFT)

Attachment A
OMB No. xxxx-xxxx-x: Approval Expires xx/xx/xxxx.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

2010 Census Quality Survey
Use a blue or black pen.

5. Please provide information for each person living here on April 1, 2010.
Start with 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
The 2010 Census counted every person living in the United
States on April 1, 2010. By answering the following
questions, you will help ensure that the 2010 Census results
are accurate.
Before you answer Question 1, count the people who lived in
this house, apartment, or mobile home on April 1, 2010 using
our guidelines.
• Count all people, including babies, who lived and slept here
most of the time.
The Census Bureau also conducts counts in institutions
and other places, so:
• Do not count anyone who lived away either at college or in
the Armed Forces on April 1, 2010.
• Do not count anyone who was in a nursing home, jail,
prison, detention facility, etc., on April 1, 2010.
• Leave these people off your form, even if they returned to
live here after they left college, the nursing home, the
military, jail, etc.

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.
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 survey, Hispanic origins are not races.

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

The Census Bureau must also include people without a
permanent place to stay, so:
• If someone who had no permanent place to stay was
staying here on April 1, 2010, count that person.

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

9. What is Person 1’s race? Mark I
J one or more boxes.
K
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or principal tribe. C

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

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

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

4. Did you fill out the 2010 Census form for this household?

Some other race — Print race. C

10. Does Person 1 sometimes live or stay somewhere else?
No

Mark I
J ONE box.
K

D-1 R1

(4-20-2010)

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

Yes. I filled out the form by myself.
Yes. I filled out the form along with somebody else.
No.
Form

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

For child custody
In jail or prison
In a nursing home
For another reason

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

USCENSUSBUREAU

1

D-1 R1 - Prints Pantone Proocess YELLOW #129 (10%. 20%, 25%,50% and 100%)
D-1 R1 - Base prints in BLACK

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Attachment A

1. Print name of Person 2

1. Print name of Person 3

Last Name

Last Name

First 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

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
Male

Female

Male

Day

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.
Month

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?
Age on April 1, 2010

MI

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

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

Year of birth

Age on April 1, 2010

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

5.

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

Question 6 about race. For this survey, Hispanic origins are not races.
Is this person of Hispanic, Latino, or Spanish origin?

Question 6 about race. For this survey, Hispanic origins are not races.

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

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

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

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

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
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

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
No

➜

7. Does this person sometimes live or stay somewhere else?

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

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

No
For child custody
In jail or prison
In a nursing home
For another reason

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

➜

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

For child custody
In jail or prison
In a nursing home
For another reason

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

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Attachment A

1. Print name of Person 5

1. Print name of Person 4
Last Name

Last Name

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

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

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.

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.

Age on April 1, 2010

Age on April 1, 2010

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

5.

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

Question 6 about race. For this survey, Hispanic origins are not races.
Is this person of Hispanic, Latino, or Spanish origin?

Question 6 about race. For this survey, Hispanic origins are not races.

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

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

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

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
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

Some other race — Print race. C

7. Does this person sometimes live or stay somewhere else?
No

➜

7. Does this person sometimes live or stay somewhere else?

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

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

No
For child custody
In jail or prison
In a nursing home
For another reason

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

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

➜

For child custody
In jail or prison
In a nursing home
For another reason

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

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Attachment A

1. Print name of Person 6
Last Name

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

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.
Age on April 1, 2010

Month

Day

Year of birth

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

Question 6 about race. For this survey, Hispanic origins are not races.
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

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

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

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
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

7. Does this person sometimes live or stay somewhere else?
No

Yes — Mark I
J
K all that apply.
In college housing
In the military
At a seasonal
or second residence

➜

For child custody
In jail or prison
In a nursing home
For another reason

If more than six people were counted in Question 1 on
the front page, turn the page and continue.
Form D-1 R1 (4-20-2010)

4
D-1 R1 - Pantone Process YELLOW #129 (10%, 25%, 50% and 100%)
D-1 R1 - Base prints BLACK

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

Draft 3 (4-20-2010)

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➞

Attachment A

Use this section to complete information for the rest of the people you counted in Question 1 on the
front page.

Person 7

Last Name

Sex

Age on April 1, 2010

Person 8

Last Name

Sex

Age on April 1, 2010

Related to Person 1?
Year

Day

Yes
No

First Name

MI

Related to Person 1?

Date of Birth
Month

Male
Female

MI

Date of Birth
Month

Male
Female

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First Name

Year

Day

Yes
No

Person 9

Last Name

Sex

Age on April 1, 2010

First Name

Date of Birth
Month

Male

MI

Related to Person 1?

Day

Year

Female

Yes
No

➞

Person 10

Last Name

Sex

Age on April 1, 2010

First Name

Related to Person 1?

Date of Birth
Month

Male

MI

Day

Year

Female

No

Person 11

Last Name

Sex

Age on April 1, 2010

First Name

MI

Related to Person 1?

Date of Birth
Month

Male

Day

Year

Yes
No

Female

Person 12

Last Name

Sex

Age on April 1, 2010

Male

Yes

First Name

MI

Related to Person 1?

Date of Birth
Month

Day

Year

Yes
No

Female

Thank you for completing the
2010 Census Quality Survey.

FOR OFFICIAL USE ONLY
JIC1

JIC2

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➞

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Attachment A

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
If you need help completing this form, call 1-866-208-7437, 7 days a week. The telephone call is
free.
TDD — Telephone display device for the hearing impaired. Call 1-800-582-8330 between
9:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

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 xxxx-xxxx-x, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project xxxx-xxxx-x" as the subject.
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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