Various Demographic Pretesting Activities

Census Household Form

GENERAL INSTRUCTIONS

Use this census form or respond online to provide information for:

• Anyone who, on October 1, 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.

You MUST RESPOND ONLINE if:

• You moved into this address after October 1, 2012.

• The address printed on the back of the form was vacant on October 1.

• The address printed on the back of the form is a seasonal home which is mostly vacant

You may use this census form or respond online:

• If you moved into this address on or before October 1.

Go to www.census.gov to find out how to respond online.

1. The Census must count every person living in the United States on October 1, 2012, where they live and sleep most of the time.

How many people were living or staying at this address on October 1, 2012?

= Number of people for Question 1

2. Were there any additional people staying here on October 1, 2012 who you did not include in Question 1?

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?

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

= Number of NEW people not already counted in Question1

3. Is this house, apartment, or mobile home—Mark  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?

4. What is your telephone number?

On the inside of this form, list all the people that you identified in Questions 1 and 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

6. What is Person 1’s sex? Mark  ONE box.

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 October 1, 2012 Month Day Year

8. 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

9. What is Person 1’s race? Mark  ONE or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 10

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

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

11. On October 1, 2012, did Person 1 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

12. Did Person 1 move into this address after September 1, 2012?

Yes—what date? ___________________

No

13. If you marked yes above indicating that Person 1 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 10, 11 or 12. Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 1 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

14. 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

15. On October 1, 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.

Person 2

1. What is Person 2’s name? Print name below

First Name

MI

Last Name

2. How is Person 2 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 2’s sex? Mark  ONE box.

Male

Female

4. What is Person 2’s age and what is Person 2’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 October 1, 2012 Month Day Year

5. Is Person 2 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

6. What is Person 2’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 2 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

8. On October 1, 2012, did Person 2 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

9. Did Person 2 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 2 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 2 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 2 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 2 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

 If more people were counted in Question 1 or 2, continue.

Person 3

1. What is Person 3’s name? Print name below

First Name

MI

Last Name

2. How is Person 3 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 3’s sex? Mark  ONE box.

Male

Female

4. What is Person 3’s age and what is Person 2’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 October 1, 2012 Month Day Year

5. Is Person 3 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

6. What is Person 3’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 3 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

8. On October 1, 2012, did Person 3 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

9. Did Person 3 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 3 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 3 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 3 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 3 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

 If more people were counted in Question 1 or 2, continue.

Person 4

1. What is Person 4’s name? Print name below

First Name

MI

Last Name

2. How is Person 4 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 4’s sex? Mark  ONE box.

Male

Female

4. What is Person 4’s age and what is Person 4’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 October 1, 2012 Month Day Year

5. Is Person 4 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

6. What is Person 4’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 4 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

8. On October 1, 2012, did Person 4 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

9. Did Person 4 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 4 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 4 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 4 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 4 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

 If more people were counted in Question 1 or 2, continue.

Person 5

1. What is Person 5’s name? Print name below

First Name

MI

Last Name

2. How is Person 5 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 5’s sex? Mark  ONE box.

Male

Female

4. What is Person 5’s age and what is Person 5’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 October 1, 2012 Month Day Year

5. Is Person 5 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

6. What is Person 5’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 5 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

8. On October 1, 2012, did Person 5 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

9. Did Person 5 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 5 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 5 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 5 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 5 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

 If more people were counted in Question 1 or 2, continue.

Person 6

1. What is Person 6’s name? Print name below

First Name

MI

Last Name

2. How is Person 6 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 6’s sex? Mark  ONE box.

Male

Female

4. What is Person 6’s age and what is Person 6’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 October 1, 2012 Month Day Year

5. Is Person 6 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

6. What is Person 6’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 6 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No, does not live or stay somewhere else

8. On October 1, 2012, did Person 6 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No, did not stay in a facility on October 1

9. Did Person 6 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 6 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where Person 6 was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 6 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 6 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

 If more people were counted in Question 1 or 2, continue.

Person 7

1. What is Person 7’s name? Print name below

First Name

MI

Last Name

2. How is Person 7 related to Person 1? Mark  ONE box.

Husband or wife Parent-in-law

Biological son or daughter Son-in-law or daughter-in-law

Adopted son or daughter Other relative

Stepson or stepdaughter Roomer or boarder

Brother or sister Housemate or roommate

Father or mother Unmarried partner

Grandchild Other nonrelative

3. What is Person 7’s sex? Mark  ONE box.

Male

Female

4. What is Person 7’s age and what is Person 7’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 October 1, 2012 Month Day Year

5. Is Person 7 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

6. What is Person 7’s race? Mark  one or more boxes.

White

Black, African American, or Negro

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

Asian Indian Japanese Native Hawaiian

Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan

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

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

Some other race—Print race

 Continue to Question 7

7. Does Person 7 sometimes live or stay somewhere else?

Mark  all that apply

Yes, for college (on or off campus)

Yes, in the military

Yes, for a job or business

Yes, with a parent or grandparent

Yes, with a friend

Yes, at another home, like a second or seasonal residence

Yes, at another place

No - does not live or stay somewhere else

8. On October 1, 2012, did Person 7 stay in a facility, like those listed below?

Yes, in jail or prison

Yes, in a nursing home or group home

Yes, in a shelter

Yes, in another type of facility

No – did not stay in a facility on October 1

9. Did Person 7 move into this address after September 1, 2012?

Yes—what date? ___________________

No

10. If you marked yes above indicating that Person 1 stays somewhere else or has moved, please provide the full address of the other place mentioned in Question 7, 8, or 9.  Provide as much address information as possible. If you do not know the full address provide whatever you can such as neighborhood, cross streets or facility name. If there is more than one place, provide the other address where person was most of the time.

Street Address (House Number and Street Name)

Apartment Number

City State ZIP Code

County/Township/Parish

Facility name (if necessary):

Other location information (if necessary):

11. Where does Person 7 live or stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 10

Both places equally

12. On October 1, 2012, where was Person 7 staying?

The address printed on the back of this questionnaire

The address or location you listed in Question 10

Some other place

RESIDENT AT:

____________________________________________________________________________________________

____________________________________________________________________________________________

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