D-1(E) Enumerator-NRFU

Draft 5 8/27/2008
OMB No. 0607-0919-C: Approval Expires 12/31/2011

RESPONDENT INFORMATION

U.S. CENSUS BUREAU

R1.
We do not want to miss any people who might have been staying here on April 1.
Were there any additional people that you didn’t mention, for example:

R2.

(Ask or verify) What is your name?
First Name

No
No
No
No
No

Yes

No

MI

Area Code
–
Day

Address of proxy

R3.

Last Name

A.

Unit Status on April 1, 2010
Occupied
Vacant - regular
Vacant - usual home elsewhere
Demolished/burned out/cannot locate
Nonresidential
Empty mobile home/trailer site
Uninhabitable (open to elements,
condemned, under construction)
Duplicate – record ID of Dup. C

Do you or does someone in this household own this (house/apartment/mobile home) with a mortgage or loan,
including home equity loans; own it free and clear; rent it; or occupy it without having to pay rent?

B.

Street name or rural route address

For rent
Rented, not occupied
For sale only
Sold, not occupied
For seasonal, recreational
or occasional use
For migrant workers
Other vacant

Number of people listed on form(s) =
1 - 49 = Total people
00 = Vacant
98 = Delete
99 = POP unknown

Tract

Block

AA

Map Spot

Are there any continuation forms for this address?
Yes ➙

UHE

D.

What language was the majority of the interview conducted in?

E.

MOV

F.
CO

I.

Other – Specify language number from flashcard ➙

PI

G.
REP

REF

H.
VDC

J.

Mo

L.

Enumerator’s signature

Employee ID

Mo

Day

S1.

JIC2

M.

:

a.m.
p.m.

:

a.m.
p.m.

Outcome

Time

Outcome

Type
Mo
Personal
Telephone
Mo
Personal
Telephone
Mo
Personal
Telephone

Hello, I’m (Name) from the U.S. Census Bureau.
(Show ID). Is this (Address)?

S4.

Yes - Continue with question S2.
No - Ask: Can you tell me where to find (Address)?
END INTERVIEW.

Crew Leader’s initials

S2.

CLD number

Month

Day

:

a.m.
p.m.

Time

Personal
Telephone

Day

I’m here to complete a Census questionnaire for this
address. It should take about 10 minutes. (Hand
respondent Information Sheet.) The first part explains
that your answers are confidential. I’ll refer to the other
parts later. Did you or anyone in this household live or
stay here on April 1, 2010?
Yes - Continue with question S3.
No - Skip to question S4.

S3.
Month

Day

Outcome

Time

Personal
Telephone

CERTIFICATION
I certify that the entries I have made on this questionnaire are
true and correct to the best of my knowledge.

Day

Day

Day

Day

Outcome

Time
:

a.m.
p.m.

:

a.m.
p.m.

:

a.m.
p.m.

Outcome

Time

Time

Outcome

OUTCOME CODES: NV = Left Notice of Visit NC = No Contact RE = Refusal CI = Conducted Interview OT = Other

K.

JIC1

ZIP Code

Go to respondent Information on back page.

Number of forms

No

Type
I
J
K Personal

Spanish

NOTES

County

RECORD OF CONTACT

English

State

State

➤

APPLY LABEL HERE

Mo

Apartment number

City

C.

If vacant, ask: Which category best
describes this vacant unit as of
April 1, 2010? (Read categories.)

If there is not an address label affixed, or if the address label includes only a location description, ask –
What is the address of this unit?
House number

LCO

–

INTERVIEW SUMMARY

Own with a mortgage or loan (including home equity loans)
Own free and clear (without a mortgage or loan)
Rent
Occupy without payment of rent

H3.

Either

Respondent Type –

Last Name

Do not list any people recorded for this question on the inside pages or on a continuation form.

H2.

Evening

Household member – Lived here on April 1, 2010
Household member – Moved in after April 1, 2010
Neighbor or other proxy

Anyone else?
First Name

–
Unit ID

Last Name

If yes to any category, ask: What is that person’s name?
First Name

Number

Does someone usually live at this
(house/apartment/mobile home), or is this a vacation
or seasonal home?
Usually lives here - Skip to question S5.
Vacation or seasonal home or held for occasional use –
Skip to "Respondent Information" on back page.

USCENSUSBUREAU

(Only ask if no household member lived here on April 1.)
On April 1, was this unit vacant, or occupied by a
different household?
Vacant - Skip to "Respondent Information" on back page.
Occupied by a different household - Using a
knowledgeable respondent, complete this
questionnaire for the Census Day household.
Not a housing unit – Skip to "Respondent Information"
on back page.

S5.

We need to count people where they live and sleep
most of the time.
Please look at list A. It contains examples of
people who should and should not be counted at
this place.
Based on these examples, how many people were
living or staying in this (house/apartment/mobile
home) on April 1?
= Number of people

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740101

Form D-1(E) (8-27-2008)

D-1(E) - Tone prints in Pantone Process Cyan - 10%, 15%, 25% and 50%

Yes
Yes
Yes
Yes
Yes

ENUMERATOR QUESTIONNAIRE

What is your phone number and best time to call?

D-1(E) - Base print in Black ink

Babies?
Foster children?
Any other relatives?
Roommates?
Any other nonrelatives?
How about anyone else staying here on April 1
who had no permanent place to live?

Economics and Statistics Administration

➤

H1.

U.S. DEPARTMENT OF COMMERCE

Draft 5 8/27/2008

Person 1
First Name

2.

Please look at list B on the Information
Sheet. How is (Name) related to (Read name
of Person 1)?

3.

Mark I
J
K ONE box.

Mark I
J
K ONE box.

I
J
K Person 1

Is (Name)
male or
female?

Male
Female

MI

4.

What was (Name’s) age on
April 1, 2010? What is
(Name’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
DATE OF BIRTH
Month

Last Name

Day

5.

Please look at List C. Is (Name) of Hispanic, Latino, or
Spanish origin?
Read if necessary:
Examples of another Hispanic, Latino, or Spanish origin
include Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C

Year of birth

Person 2
First Name

MI

Last Name

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

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate

Age on
April 1, 2010
DATE OF BIRTH
Month
Day

Unmarried partner
Other nonrelative

First Name

MI

Last Name

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

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate

Age on
April 1, 2010
DATE OF BIRTH
Month
Day

Unmarried partner
Other nonrelative

Please look at List D and choose one or more races. For this census, Hispanic origin is not a race.
What is (Name’s) race?
Read if necessary:
Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
Examples of other Pacific Islander groups include Fijian, Tongan, and so on.

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Some other race — What is that group?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C

Year of birth

Person 3

6.

Year of birth

First Name

MI

Last Name

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

Male
Female

Other relative
Roomer or boarder
Housemate
or roommate

Age on
April 1, 2010
DATE OF BIRTH
Month

Unmarried partner
Other nonrelative

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C

Day
Year of birth

Person 5
First Name

Last 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

Male
Female

Age on
April 1, 2010
DATE OF BIRTH
Month
Day
Year of birth

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

FORM D-1(E) (8-27-2008)

Other Asian — What is that group? C

Other Pacific Islander — What is that group?

➙

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian or
Chamorro

Samoan

Other Asian — What is that group? C

Other Pacific Islander — What is that group?

➙

Mark I
J
K all reasons 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

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

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
No

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Other Asian — What is that group? C

Other Pacific Islander — What is that group?

➙

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
No

White

Black,
African American,
or Negro

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Native
Hawaiian

Guamanian
or Chamorro

Samoan
➙

Read response categories.

No

White

Some other race — What is that group?

Does (Name) sometimes live
or stay somewhere else for
any of these reasons? –

No

American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native

Some other race — What is that group?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C

➙

Black,
African American,
or Negro

Some other race — What is that group?

Person 4

Other Pacific Islander — What is that group?

White

Some other race — What is that group?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C

Other Asian — What is that group? C

7.

D-1(E) - Tone prints in Pantone Process Cyan - 10%, 25% and 50%

Let’s make a list of all those people. Please start with
the name of an owner or renter who was living here
on April 1. Otherwise, start with any adult living here.

Other Asian — What is that group? C

Other Pacific Islander — What is that group?

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
No

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740102

D-1(E) - Base print in Black ink

1.