D-15 Enum at Transitory Locations

Draft 5 9-10-2008
OMB No. 0607-0919-C: Approval Expires 12/31/2011

NOTES

RECORD OF CONTACT

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Type

Month

Day

TRANSITORY LOCATION QUESTIONNAIRE

Outcome

Time
a.m.
p.m.

Personal
OUTCOME CODE: CI = Conducted Interview

RESPONDENT INFORMATION
R1.

R2.

(Ask or verify) What is your name?

LCO

State

County

Tract

Block

AA

Map Spot

What is your phone number and best time to call?
We may call if we don’t understand an answer.

MI

First Name

Area Code

Number
–

Last Name
Day

–
Evening

Either

Address of proxy

R3.

Respondent Type –
Neighbor or other proxy
➤

➤

APPLY LABEL HERE

Are there any continuation forms for
this address?

INTERVIEW SUMMARY

Yes ➙ Number of forms

A.

Status of unit:

B.

01 = Occupied

C.

POP

What language was the majority of the interview conducted in?

01 - 49

JIC1

English
Spanish
Other – Specify language number from flashcard ➙

No

S1.

I will complete a census questionnaire for all the people staying at this (RV/boat/room/unit) who have no other place
they usually live and sleep. This should take about 10 minutes. (Hand respondent the Information Sheet, if necessary.)
The first part of this sheet explains that your answers are confidential. I’ll refer to the other parts later.

S2.

Confirm location address and unit designation.
House Number

JIC2

D.

E.

Unit Designation

CERTIFICATION
Street name or rural route address
I certify that the entries I have made on this questionnaire are
true and correct to the best of my knowledge.

Crew Leader’s initials

Enumerator’s signature

CLD number

City
Employee ID

State

ZIP Code

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Household member

Location Description

Month

Day

Day

S3.

Do you or does someone in this household own this (RV/boat/room/unit) with a mortgae or loan, including home equity loans;
own it free and clear; rent it; or occupy it without having to pay rent?
Own with a mortgage or loan (including home equity loans)
Own free and clear (without a mortgage or loan)
Rent
Occupy without payment or rent

S4.

Including yourself, how many people are living or staying in this (RV/boat/room/unit) who have no other place they
usually live?
Number of people =

USCENSUSBUREAU

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FORM D-15 (9-10-2008)

D-15 - Base print in Black ink

Month

Draft 5 9/10/2008

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

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

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

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

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

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

FORM D-15 (9-10-2008)

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 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?
➙

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?
➙

Read response categories.
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

Other Asian — What is that group? C

Other Pacific Islander — What is that group?
➙

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

No

White

Some other race — What is that group?

7.

No

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

➙

Some other race — What is that group?

Year of birth

Person 5

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.

Some other race — What is that group?

Year of birth

Person 4

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?

Some other race — What is that group?

Year of birth

Person 3

6.

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

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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1.