Various Demographic Area Pretesting Activities

Paper Census Household Form

GENERAL INSTRUCTIONS

Who should use this paper form?

• Anyone who, on January 15, 2012, was living or staying at the address printed on this form.

• Anyone who lives and sleeps most of the time at the address printed on this form.

• Anyone whose entire household moved into this address on or before January 15, 2012.

Who should respond online?

• Anyone whose entire household moved into this address printed on this form after January 15, 2012.

• Anyone who needs to report that the address printed on this form was vacant on January 15, 2012.

• Anyone who needs to report that the address printed on this form is a seasonal home.

CENSUS QUESTIONS

1. T

   
   
   

   he Census must count every person living in the United States on January 15, 2012, where they live and sleep most of the time. How many people were living or staying at this address on January 15, 2012?

= Number of people for Question #1

2. Certain types of people are sometimes left off the census. Were there any additional people staying here January 15, 2012 that you did not include in Question #1, for example:

Yes  No  Babies?

Yes  No  Foster children?

Yes  No  Any other relatives?

Yes  No  Roommates or people not related to you?

Yes  No  People staying here temporarily?

Y

es  No  Anyone staying here who had no permanent place to live?

= Number of ADDITIONAL people for Question #2

2. 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?

2. W

   
   
   

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

On the inside of this form, list all the people reported in Question 1 and Question 2.

Person 1

5. Please provide information for each person counted in Questions #1 and #2. 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

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 printed on the back of this questionnaire

• 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 printed on the back of this questionnaire

• The address or location you listed in Question 13.

• Some other place

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

• 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