Various Demographic Area Pretesting Activities

Paper Census Be Counted Form

Who should be listed on this form?

• Include yourself if you have not been counted in the 2010 Census.

• Include anyone else who was living with you on January 15, 2012 who has not yet been counted.

• Include family members, babies, nonrelatives, and anyone else who lives and sleeps at your address most of the time and has not been counted.

1. What was the physical address of the place you were living or staying on January 15, 2012?

• Please do not provide a PO Box address. If you have a 911, or emergency services address, provide that address.

• If you have more than one residence, provide the address of the place where you live most of the time.

Street Address (House Number and Street Name)

[][][][][][][][][][][][][][][][][][][][][][][][][][][][][][]

[][][][][][][][][][][][][][][][][][][][][][][][][][][][][][]

Apartment Number

[][][][][][][][][][][][][][][][][][][][][][][][][][][][][][]

City State ZIP Code

[][][][][][][][][][][][][][][][][][][][][][][][][][][][][][] [][] [][][][][]

County/Township/Parish

[][][][][][][][][][][][][][][][][][][][][][][][][][][][][][]

2. On January 15, 2012, were you experiencing homelessness?

[] Yes – Please provide as much information to Question 1 above about where you stayed on January 15^th as possible, including facility name, cross streets, park city, county, and state .

[] No

3. Is this house, apartment or mobile home—Mark X ONE box

• 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?

3. What is your telephone number? We may call if we don’t understand an answer.

3. Were there any other people who lived at this address on January 15^th?

1. YES - Are you completing this form for…

• ALL of them?

• SOME of them?

• Just yourself?

2. No

On the inside of this form, list all the people who live with you and have not been counted.

Person 1

6. If you are completing this form for ALL of the people living at this address, start with a person living here who owns or rents this house or apartment. Otherwise, start with yourself. This will be Person 1.

What is Person 1’s name? Print name below

First Name MI

Last Name

5. What is Person 1’s sex? Mark X ONE box.

Male Female

5. 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 January 15, 2012 Month Day Year of Birth

5. Is Person 1 of Hispanic, Latino, or Spanish Origin?

• 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---Print origin, for example, Argentinean, Columbian, Dominican, Nicaraguan, Salvadorian, Spaniard, and so on

5. What is Person 1’s race? Mark X one or more boxes.

• White

• Black, African American, or Negro

• American Indian or Alaska Native—Print name of enrolled or principal tribe

• Some other race—Print race

• Continue to Question 10

Some people live or stay in more than one place and we would like to make sure everyone is only counted once.

10. Does Person 1 sometimes live or stay somewhere else?

• Yes—Mark X all that apply

• No

10. On January 15, 2012, did Person 1 stay in another type of place?

• Yes-Mark X all that apply

• No

10. Did person 1 move during January?

• Yes—what date? ___________________

• No

10. If you marked yes to Question 10, 11, or 12 please provide the full address of the other place :

If there is more than one place, provide the other address where you were most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State Zip Code

County

• NOTE: If you do not know the address, provide the neighborhood or community, cross streets or facility name:

10. Where does Person 1 live or stay most of the time?

• The address you wrote on Page 1

• The address or location listed in Question 13

• Both places equally

• Some other place

10. On January 15, 2012, where was Person 1 staying?

• The address you wrote on Page 1

• The address or location you listed in Question 13.

• Some other place

­­ Continue with information about the next person who has not been counted.

• For College (on or off campus)

• In the Military

• For a job or business

• With a parent or grandparent

• At another home, like a second or seasonal home

• Another place

• In jail or prison

• In a nursing home or group home

• Another place

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander—Print race, for example, Fijian, Tongan, and so on

• Asian Indian

• Chinese

• Filipino

• Other Asian—Print race, for example Hmong, Laotian, Thai, Pakistani, Cambodian, and so on

• Japanese

• Korean

• Vietnamese