D-1340 U.S. Final Housing Unit Followup Form

2010 Census Coverage Measurement Final Housing Unit Followup and Address Frame Accuracy & Quality Evaluation

Attachment A, D-1340

Final Housing Unit Followup

OMB: 0607-0962

Document [doc]
Download: doc | pdf

Attachment 1

Form D-1340 OMB No. xxxx-xxxx EXPIRES: xx/xx/xxxx <LCO #>.<CLUSTER#> Page 0 of 223

[Put Barcode here]


FORM D-1340 (06/03/2010) U.S. DEPARTMENT OF COMMERCE

OMB No. xxxx-xxxx: Economics and Statistics Administration

Approval Expires xx/xx/xxxx U.S. CENSUS BUREAU

Census Coverage Measurement (CCM)

Final Housing Unit Followup (FHUFU) Packet Cover Page

2010 Census

A. Cluster Identification B. Followup Units in Packet

1. Cluster No.


2. LCO name


3. Code

4. County


5. Code

6. State


7. Code


8. TEA


9. City

10. ZIP


Block Number

Number of Followup Units per Block











Total Number of Followup Units______














C. Field Staff Identification


Position


(a)


CLD


(b)


Name


(c)


FR Code

(d)

Dates

Assigned

(e)

Completed

(f)

Month

Day

Month

Day

1. Crew leader




| | |

| | |

| | |

| | |

2. Interviewer




| | |

| | |

| | |

| | |

3. Interviewer




| | |

| | |

| | |

| | |


CENSUS CONFIDENTIAL: RESTRICTED DATA FOR OFFICIAL USE ONLY. Information contained in this report is for use by the Census Bureau and is confidential by law (Title 13, U.S.C.). It may be seen only by persons sworn to protect the confidentiality of the data and may be used only for statistical purposes. Access restricted to authorized CCM staff.


NOTICE TO FINDER: If found, please either call 1-301-763-3301 to arrange for pickup OR mail to: Field Division, U.S. Census Bureau, 4600 Silver Hill Road, Washington, DC 20233-5700, Attn: Coverage Measurement Branch.

CCM Nonmatched Address (NI)


The CCM listed an address that the Census did not. Determine if the CCM address is a housing unit.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX





 


 

 

 

CCM ADDRESS


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 6

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business……………………………………………………………………………………………………………

  • Other Explain what is on the ground; continue on back and draw sketch map if needed


________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 7

3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________


___________________________________________________________________________


4. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


5. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


6. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


7. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Census Nonmatched Address (NE)


The Census listed an address that CCM did not. Determine if the Census address is a housing unit.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN








XXXXXXX





CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 6

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

  • Other Explain what is on the ground; continue on back and draw sketch map if needed


________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 7

3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


4. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


5. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


6. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?


7. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE






Possible CCM-Census Match (P)


The CCM and Census addresses are possible matches. Determine if the CCM and Census addresses are the same.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX








YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other __________________________________________________

No Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________

___________________________________________________________________________



4. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


STOP if you answered “Yes” to Question 2


CCM ADDRESS


5. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down……………………………………………………………………………………….

  • Boarded up…………………………………………………………………………………………………..……….

Unit used for storage of non-household goods…………………………………………………………….……. Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………….. Question 9

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business…………………………………………………………………………………………………………. …

  • Other Explain what is on the ground; continue on back and draw sketch map if needed


________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 10


6. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________





7. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


8. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


9. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?



CENSUS ADDRESS


10. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 14

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed


________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 15










11. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


12. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit , then enter the map

spot number here:


13. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


14. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?

15. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


CCM-Census Match/Duplicate CCM Address (M/DI)


The CCM and Census address match. The CCM address is a possible duplicate with another CCM address. Determine if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX







 

 

 

CCM ADDRESS 2


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


CCM DUPLICATE ADDRESSES

2. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? _________________________________________________


b. What is the correct block? (C2)

XXXXXXX

Other _________________________________________________

No ® Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


__________________________________________________________________________

__________________________________________________________________________

4. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


STOP if you answered “Yes” to Question 2

SECOND CCM ADDRESS


5. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 9

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

_________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 10



6. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


7. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

  • No


8. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


9. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CCM ADDRESS 2?


10. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

















CCM-Census Match/Duplicate Census Address (M/DE)


The CCM and Census address match. The Census address is a possible duplicate with another Census address. Determine if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1

 

 

 

 

 

 


YYYYYYY




 


CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


CENSUS DUPLICATE ADDRESSES

2. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? __________________________________________________


b. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _________________________________________________

No ® Skip to Question 5







3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


STOP if you answered “Yes” to Question 2


SECOND CENSUS ADDRESS


5. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………....

  • Future construction…………………………………………………………………………………………………

Unfit for habitation (condemned or open to the elements) and unoccupied………………………………….

  • Demolished or burned down……………………………………………………………………………………….

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 9

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 10







6. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


7. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map spot

number here:


8. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


9. Is CENSUS ADDRESS 2 located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


10. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)


The CCM and Census address match. The CCM addresses are possible duplicates with other CCM addresses. Determine if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX






 

 

 

 

 

 

CCM ADDRESS 2


 


YYYYYYY






 

 

 

 

 

 

CCM ADDRESS 3

 



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


FIRST CCM DUPLICATE ADDRESS

2. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? _________________________________________________


b. What is the correct block? (C2)

XXXXXXX

Other _________________________________________________

No ® Skip to Question 4






3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


SKIP to Question 9 if you answered “Yes” to Question 2


SECOND CCM ADDRESS


4. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…..…….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down……………………………………………………………………………………….

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

7. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


8. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS

9. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? _________________________________________________


b. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _________________________________________________

No ® Skip to Question 11

10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


SKIP to Question 16 if you answered “Yes” to Question 9













THIRD CCM ADDRESS


11. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………...

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down……………………………………………………………………………………....

  • Boarded up…………………………………………………………………………………………………..……..

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 15

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 16


12. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


13. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


14. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 2, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No



15. Is CCM ADDRESS 3 located in block YYYYYYY? (B)

Yes

No In what block number is CCM ADDRESS 3?


16. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form





FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE







CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)


The CCM and Census address match. The Census addresses are possible duplicates with other Census addresses. Determine if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]



FIRST CENSUS DUPLICATE ADDRESS

2. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? _________________________________________________


b. What is the correct block? (C2)

XXXXXXX

Other _________________________________________________

No ® Skip to Question 4




3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


SKIP to Question 9 if you answered “Yes” to Question 2


SECOND CENSUS ADDRESS


4. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….……..….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

6. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the

map spot number here:


7. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 3 do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


8. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS

9. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________________________

No Skip to Question 11

10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


SKIP to Question 16 if you answered “Yes” to Question 9









THIRD CENSUS ADDRESS


11. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….……. ….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 15

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 16


12. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


13. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:

14. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


15. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


16. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation



Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




CCM Nonmatched and Duplicate Address (NI/DI)


The CCM listed an address that the Census did not. The CCM address is a possible duplicate with another CCM address. Determine if the CCM address is a housing unit and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX










CCM ADDRESS 1



XXXXXXX












CCM ADDRESS 2



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]



CCM DUPLICATE ADDRESS

2. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other ____________________________________ Skip to Question 8

No








SECOND CCM ADDRESS


3. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)………………………………………………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


5. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

6. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No

7. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?

CCM NONMATCH ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….……..….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied………………………………….

  • Demolished or burned down………………………………………………………………………………….…...

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business……………………………………………………………………………………………………………..

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13

9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No




11. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?


13. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Census Nonmatched and Duplicate Address (NE/DE)


The Census listed an address that CCM did not. The Census address is a possible duplicate with another Census address. Determine if the Census address is a housing unit and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN








XXXXXXX







CENSUS ADDRESS 1








XXXXXXX







CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]



CENSUS DUPLICATE ADDRESS

2. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No










SECOND CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)………………………………………………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business………………………………………………………………………………………………………….….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No

7. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


CENSUS NONMATCH ADDRESS


8. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….……..….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business…………………………………………………………………………………………………………. ….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


10. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:




11. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


12. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?


13. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Unit Status Update (M*)


The CCM and Census addresses match, but the unit status was listed by CCM as something other than occupied or vacant. Determine the unit status of the CCM address.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5

3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

Other _____________________________________


5. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Unit Status Update/Duplicate CCM Address (M*/DI)


The CCM and Census addresses match, but the unit status was listed by CCM as something other than occupied or vacant. The CCM address is a possible duplicate with another CCM address. Determine the unit status of the CCM address and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX










CCM ADDRESS 2




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]






























2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business………………………………………………………………………………………………………….….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

Other _____________________________________










CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No


SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business…………………………………………………………………………………………………………. ….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

STOP – Go to Next Form






Unit Status Update/Duplicate Census Address (M*/DE)


The CCM and Census addresses match, but the unit status was listed by CCM as something other than occupied or vacant. The census address is a possible duplicate with another census address. Determine the unit status of the CCM address and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








XXXXXXX





CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]

































2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

Other _____________________________________


CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________



8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit , then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


Unit Status Update/Two Duplicate CCM Addresses (M*/DI/DI)


The CCM and Census addresses match, but the unit status was listed by CCM as something other than occupied or vacant. The CCM addresses are possible duplicates with other CCM addresses. Determine the unit status of the CCM address and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]

























2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

Other _____________________________________

FIRST CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No


SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 3, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS


11. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No


THIRD CCM ADDRESS


12. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17


13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


14. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


15. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No





16. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Unit Status Update/Two Duplicate Census Addresses (M*/DE/DE)


The CCM and Census addresses match, but the unit status was listed by CCM as something other than occupied or vacant. The census addresses are possible duplicates with other census addresses. Determine the unit status of the CCM address and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]




























2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

Other _____________________________________










FIRST CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit , then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS


11. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No




THIRD CENSUS ADDRESS


12. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17

13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

14. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


15. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit as

CENSUS ADDRESS 3?

Yes Enter Census ID:

No




16. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE







Surrounding Block Match (M*)


The CCM and Census addresses were matched, but the blocks for the two addresses are different. Determine the correct block.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5

3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _____________________________________


5. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Surrounding Block Match/Duplicate CCM Address (M*/DI)


The CCM and Census addresses were matched, but the blocks for the two addresses are different. The CCM address is a possible duplicate with another CCM address. Determine the correct block and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX










CCM ADDRESS 2




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]































2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _____________________________________









CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?

11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

STOP – Go to Next Form





Surrounding Block Match/Duplicate Census Address (M*/DE)


The CCM and Census addresses were matched, but the blocks for the two addresses are different. The Census address is a possible duplicate with another Census address. Determine the correct block and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS 1








YYYYYYY





CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]

































2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

Other _____________________________________

CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 2?



11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)


The CCM and Census addresses were matched, but the blocks for the two addresses are different. The CCM addresses are possible duplicate with other CCM addresses. Determine the correct block and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]

























2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

Other _____________________________________

FIRST CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 3, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS


11. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No


THIRD CCM ADDRESS


12. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17


13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


14. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


15. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No





16. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Surrounding Block Match/Two Duplicate Census Addresses (M*/DE/DE)


The CCM and Census addresses were matched, but the blocks for the two addresses are different. The Census addresses are possible duplicates with other Census addresses. Determine the correct block and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

YYYYYYY







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]





























2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

YYYYYYY

Other _____________________________________










FIRST CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS


11. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No

THIRD CENSUS ADDRESS


12. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17

13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


14. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


15. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 3?

Yes Enter Census ID:

No




16. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 3?


17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE







Unit Status Update and Surrounding Block Match (M*)


The CCM and Census addresses were matched, but the unit status was listed by CCM as something other than occupied or vacant and the blocks for the two addresses are different. Determine the unit status and the correct block.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]

































2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………...

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _____________________________________















5. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Unit Status Update and Surrounding Block Match/Duplicate CCM Address (M*/DI)


The CCM and Census addresses were matched, but the unit status was listed by CCM as something other than occupied or vacant and the blocks for the two addresses are different. The CCM address is a possible duplicate with another CCM address. Determine the unit status, the correct block, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX










CCM ADDRESS 2




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]





























2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _____________________________________









CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No


SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

STOP – Go to Next Form






Unit Status Update and Surrounding Block Match/Duplicate Census Address (M*/DE)


The CCM and Census addresses were matched, but the unit status was listed by CCM as something other than occupied or vacant and the blocks for the two addresses are different. The census address is a possible duplicate with another census address. Determine the unit status, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

YYYYYYY







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








XXXXXXX





CENSUS ADDRESS 2

Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?


1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]









2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

YYYYYYY

Other _____________________________________














CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No

SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit , then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 2?



11. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


Unit Status Update and Surrounding Block Match/Two Duplicate CCM Addresses (M*/DI/DI)


The CCM and Census addresses were matched, but the unit status was listed by CCM as something other than occupied or vacant and the blocks for the two addresses are different. The CCM addresses are possible duplicates with other CCM addresses. Determine the unit status, the correct block, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]






















2. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2)

XXXXXXX

YYYYYYY

Other _____________________________________


FIRST CCM DUPLICATE ADDRESS


5. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No


SECOND CCM ADDRESS


6. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11

7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


8. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

9. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 3, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


10. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?

SECOND CCM DUPLICATE ADDRESS


11. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No









THIRD CCM ADDRESS


12. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17


13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


14. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


15. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No





16. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Unit Status Update and Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)


The CCM and Census addresses were matched, but the unit status was listed by CCM as something other than occupied or vacant and the blocks for the two addresses are different. The census addresses are possible duplicates with other census addresses. Determine the unit status, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

YYYYYYY







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


























2. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 4

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 5


3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


4. What is the correct block? (C2) XXXXXXX

YYYYYYY

Other _____________________________________










FIRST CENSUS DUPLICATE ADDRESS


5. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 11

Other __________________________________ Skip to Question 11

No


SECOND CENSUS ADDRESS


6. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………...

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 10

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 11












7. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


8. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


9. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


10. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 2?



SECOND CENSUS DUPLICATE ADDRESS


11. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 17

Other __________________________________ Skip to Question 17

No




THIRD CENSUS ADDRESS


12. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 16

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


__________________________________________________

Business……………………………………………………………………………………………………………...

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 17

13. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


14. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


15. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 3?

Yes Enter Census ID:

No




16. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

  • No In what block number is CENSUS ADDRESS 3?



17. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE






CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)


The CCM listed an address that the Census did not. The CCM addresses are possible duplicates with other CCM addresses. Determine if the CCM address is a housing unit and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX










CCM ADDRESS 1



XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]



FIRST CCM DUPLICATE ADDRESS

2. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No






SECOND CCM ADDRESS


3. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


5. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

6. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


7. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS

8. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 14

Other __________________________________ Skip to Question 14

No

THIRD CCM ADDRESS


9. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14







10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


11. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No

12. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 2, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No


13. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


CCM NONMATCH ADDRESS


14. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2 and (F3)

CCM ADDRESS 3, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)


The Census listed an address that CCM did not. The Census addresses are possible duplicates with other Census addresses. Determine if the Census address is a housing unit and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN








XXXXXXX





CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]



FIRST CENSUS DUPLICATE ADDRESS

2. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No


SECOND CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as

CENSUS ADDRESS 2?

Yes Enter Census ID:

No





7. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS

8. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 14

Other __________________________________ Skip to Question 14

No

THIRD CENSUS ADDRESS


9. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14

10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


11. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


12. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3)

CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


13. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


CENSUS NONMATCH ADDRESS


14. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2 and (G3)

CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as

CENSUS ADDRESS 1?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Group Quarters (GQ)


CCM listed the address as a housing unit, but Census listed it as a group quarters. Determine if the CCM address is a housing unit or a group quarters.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello my name is (your name). I’m from the U.S. Census Bureau (show your identification badge). I’d like to speak with (H)

someone who can answer questions about this place. Would that be you, or should I speak with someone else?

(Continue, or if referred to another respondent, re-read paragraph above).


We are checking addresses in this area as part of the 2010 Census. The questions should take about 3 minutes. This notice explains that your answers are confidential. (Hand the person the Confidentiality Notice and allow time for the person to read it.)

READ IF NECESSARY: I won’t need to interview residents here; I just want to ask some very basic questions about this place.


1. [Go to next question./Fill question or note from analyst beginning with: Special question:________________________ (M)


______________________________________________________________________________________________


______________________________________________________________________________________________ ]

If a possible match print:
Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________

No



2. Next I’m going to show you a list [HAND FLASHCARD TO RESPONDENT]. Which of these best describes (I)

this place (CCM Address)?

A: Boarding school (except for schools for people with disabilities)….………………………………………… Skip to Question 9

B: Correctional facility for adults or juveniles……………………………………………………………………… Skip to Question 9

C: Fraternity or sorority house for students at a college, university, or seminary.……………………….….... Skip to Question 9

D: Group home (non-correctional) or residential treatment center (non-correctional)………………….…… Skip to Question 9

E: Health care facility (e.g., skilled nursing facility, nursing facility, hospital, hospice)…………………….. ...Skip to Question 9

F: Hotel, motel, hostel, single-room occupancy units, inn, resort, lodge, or bed & breakfast…………………Skip to Question 9

G: Independent living or assisted living facility……………………………………………………………………..Skip to Question 4

H: Military quarters (e.g., barrack/dormitory, disciplinary barrack/jail, military treatment facility)…………..…Skip to Question 9

I: Recreational vehicle (RV) park, campground, marina, or racetrack…………………………………...……...Skip to Question 5

J: Religious group living quarters intended to house members living in a group situation (e.g., convent,

monastery, or abbey)………………………………………………………………………………………….…...Skip to Question 9

K: Residence hall or dormitory for students that is owned, leased, or managed either by a college,

university or seminary, or by a private entity or organization…….……………………………..……...…… Skip to Question 9

L: Schools for people with disabilities (e.g., schools for the physically or developmentally disabled)….…… Skip to Question 9

M: Soup kitchen, a facility that operates a regularly schedule mobile food van, or shelter for people

experiencing homelessness……………………………………………………………………………………... Skip to Question 9

N: Workers’ group living quarters or group housing at Job Corps centers (e.g., migratory farm worker quarters, ranch

housing, vocational training facilities, or housing for staff)………………………………….………………...Skip to Question 9

O: None of the above………………………………………………………………………………………..…….…. Skip to Question 3


3. Is this a private residence? (J)

Yes Skip to Question 5

No Go to Question 4


4. Please describe this place: _________________________________________________________________________ (K)

_________________________________________________________________________


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


6. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


7. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


8. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


9. Main source of information you used to fill out questions: (N)

NOTE: You cannot complete this case by observation.

Household member

Building manager or landlord

Proxy


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

STOP – Go to Next Form





Possible CCM-Census Match/Duplicate CCM Address (P/DI)


The CCM and Census addresses are possible matches. The CCM address is a possible duplicate with another CCM address. Determine if the CCM and Census addresses are the same and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX







 

 

 

CCM ADDRESS 2


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________

No Skip to Question 4






3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________

___________________________________________________________________________


SKIP to Question 14 if you answered “Yes” to Question 2


FIRST CCM ADDRESS


4. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


7. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


8. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?


CENSUS ADDRESS


9. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14


10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

_____________________________________________________________________

11. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit then enter the map

spot number here:


12. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


13. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?

CCM DUPLICATE ADDRESS

14. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 20

Other ________________________________ ® Skip to Question 20

No


SECOND CCM ADDRESS


15. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 19

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 20


16. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


17. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

  • No


18. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


19. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

  • No In what block number is CCM ADDRESS 2?

20. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Possible CCM-Census Match/Duplicate Census Address (P/DE)


The CCM and Census addresses are possible matches. The Census address is a possible duplicate with another census address. Determine if the CCM and Census addresses are the same and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








YYYYYYY

 

 



CENSUS ADDRESS 2 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________

No Skip to Question 4





3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________

___________________________________________________________________________


SKIP to Question 14 if you answered “Yes” to Question 2


CCM ADDRESS


4. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


7. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


8. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


FIRST CENSUS ADDRESS


9. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14


10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

11. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


12. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


13. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?

CENSUS DUPLICATE ADDRESS

14. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 20

YYYYYYY Skip to Question 20

Other __________________________________ Skip to Question 20

No



SECOND CENSUS ADDRESS


15. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 19

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 20


16. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


17. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit , then enter the map

spot number here:


18. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No

19. Is CENSUS ADDRESS 2 located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


20. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Possible CCM-Census Match/Two Duplicate Census Addresses (P/DE/DE)


The CCM and Census addresses are possible matches. The Census addresses are possible duplicates with other census addresses. Determine if the CCM and Census addresses are the same and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________

No Skip to Question 4








3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________

___________________________________________________________________________


SKIP to Question 14 if you answered “Yes” to Question 2


CCM ADDRESS


4. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


7. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


8. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


FIRST CENSUS ADDRESS


9. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14


10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

11. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the

map spot number here:


12. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2 and CENSUS (G3)

ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


13. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?

FIRST CENSUS DUPLICATE ADDRESS

14. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 20

Other __________________________________ Skip to Question 20

No



SECOND CENSUS ADDRESS


15. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 19

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 20


16. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


17. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


18. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and CENSUS (G3)

ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No




19. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?

SECOND CENSUS DUPLICATE ADDRESS

20. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 26

Other __________________________________ Skip to Question 26

No


THIRD CENSUS ADDRESS


21. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 25

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 26

22. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


23. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


24. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


25 Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


26. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Possible CCM-Census Match/Two Duplicate CCM Addresses (P/DI/DI)


The CCM and Census addresses are possible matches. The CCM addresses are possible duplicate with other CCM address. Determine if the CCM and Census addresses are the same and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX

Other __________________________________

No Skip to Question 4






3. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


___________________________________________________________________________

___________________________________________________________________________


SKIP to Question 14 if you answered “Yes” to Question 2


FIRST CCM ADDRESS


4. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 8

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 9


5. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

6. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No

7. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


8. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?


CENSUS ADDRESS


9. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 13

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 14


10. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________

11. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


12. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


13. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?

FIRST CCM DUPLICATE ADDRESS

14. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 20

Other _______________________________ Skip to Question 20

No

SECOND CCM ADDRESS


15. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 19

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 20


16. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


17. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No

18. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


19. Is CCM ADDRESS 2 located in block YYYYYYY? (B)

Yes

No In what block number is CCM ADDRESS 2?

SECOND CCM DUPLICATE ADDRESS

20. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 26

Other __________________________________ Skip to Question 26

No


THIRD CCM ADDRESS


21. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 25

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 26

22. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


23. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No

24. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 2, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No


25. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


26. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE





Unit Status Update/Possible CCM-Census Match (P*)


The CCM and Census addresses are possible matches, and the unit status was listed by CCM as something other than occupied or vacant. Determine if the addresses are the same and the unit status of the CCM address.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

YYYYYYY Skip to Question 8

Other __________________________________ Skip to Question 8

No














CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?


CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?

13. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation



Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Unit Status Update/Possible CCM-Census Match/Duplicate CCM Address (P*/DI)


The CCM and Census addresses are possible matches, and the unit status was listed by CCM as something other than occupied or vacant. Determine the unit status of the address and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX







 

 

 

CCM ADDRESS 2


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No











CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?


FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

CCM DUPLICATE ADDRESS


13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


STOP – Go to Next Form





Unit Status Update/Possible CCM-Census Match/Duplicate Census Address (P*/DE)


The CCM and Census addresses are possible matches, and the unit status was listed by CCM as something other than occupied or vacant. Determine if the addresses are the same, the unit status of the CCM address, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








XXXXXXX 

 

 



CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other ________________________________ Skip to Question 8

No





FIRST CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS 1 located in block YYYYYYY? (B)

Yes

 No  In what block number is CENSUS ADDRESS 1?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?

CENSUS DUPLICATE ADDRESS


13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CENSUS ADDRESS


14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Unit Status Update/Possible CCM-Census Match/Two Duplicate Census Addresses (P*/DE/DE)


The CCM and Census addresses are possible matches, but the unit status was listed by CCM as something other than occupied or vacant. Determine if the addresses are the same, the unit status of the CCM address, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other ________________________________ ® Skip to Question 8

No


CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2 (G3)

and CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 1?

Yes Enter Census ID:

No

7. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No

12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


FIRST CENSUS DUPLICATE ADDRESS

13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other __________________________________® Skip to Question 19

No


SECOND CENSUS ADDRESS

14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3) CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS

19. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other ____________________________________® Skip to Question 25

No




THIRD CENSUS ADDRESS


20. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the

map spot number here:


23. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


24. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE








Unit Status Update/Possible CCM-Census Match/Two Duplicate CCM Addresses (P*/DI/DI)


The CCM and Census addresses are possible matches, and the unit status was listed by CCM as something other than occupied or vacant. Determine if the addresses are the same, the unit status of the CCM address, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other _____________________________ ® Skip to Question 8

No

CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?


FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

FIRST CCM DUPLICATE ADDRESS

13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other _______________________________® Skip to Question 19

No


SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19


15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS

19. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other _____________________________________® Skip to Question 25

No


THIRD CCM ADDRESS


20. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the (E)

same housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


23. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No

24. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE












Surrounding Block Match/Possible CCM-Census Match (P*)


The CCM and Census addresses are possible matches, and the blocks for the two addresses are different. Determine if the addresses are the same and the correct block.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

YYYYYYY ® Skip to Question 8

Other __________________________________ ® Skip to Question 8

No

CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

 No  In what block number is CENSUS ADDRESS?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?

13. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation



Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE




Unit Status Update and Surrounding Block Match/Possible CCM-Census Match (P*)


The CCM and Census addresses are possible matches, the unit status was listed by CCM as something other than occupied or vacant, and the blocks for the two addresses are different. Determine if the addresses are the same, the unit status, and the correct block.


CCM Address


Census Address

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







YYYYYYY



CCM ADDRESS


CENSUS ADDRESS


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

YYYYYYY ® Skip to Question 8

Other __________________________________ ® Skip to Question 8

No

CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?

13. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation



Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE










Surrounding Block Match/Possible CCM-Census Match/Duplicate Census Address (P*/DE)


The CCM and Census addresses are possible matches, and the blocks for the two addresses are different. Determine if the addresses are the same, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








XXXXXXX 

 

 



CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other ________________________________ Skip to Question 8

No





FIRST CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS 1 located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS 1?


CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


CENSUS DUPLICATE ADDRESS


13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CENSUS ADDRESS


14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19



15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


Unit Status Update and Surrounding Block Match/Possible CCM-Census Match/Duplicate Census Address (P*/DE)


The CCM and Census addresses are possible matches, the unit status was listed by CCM as something other than occupied or vacant, and the blocks for the two addresses are different. Determine if the addresses are the same, the unit status, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1








XXXXXXX 

 

 



CENSUS ADDRESS 2


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other ________________________________ Skip to Question 8

No





FIRST CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 1?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS 1 located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS 1?


CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


CENSUS DUPLICATE ADDRESS


13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CENSUS ADDRESS


14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19



15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1, do any other (G2)

addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE






Surrounding Block Match/Possible CCM-Census Match/Duplicate CCM Address (P*/DI)


The CCM and Census addresses are possible matches, and the blocks for the two addresses are different. Determine if the addresses are the same, the correct block, and if the addresses no the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX







 

 

 

CCM ADDRESS 2


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No




CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?


FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

CCM DUPLICATE ADDRESS


13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE


STOP – Go to Next Form







Unit Status Update and Surrounding Block Match/Possible CCM-Census Match/Duplicate CCM Address (P*/DI)


The CCM and Census addresses are possible matches, the unit status was listed by CCM as something other than occupied or vacant, and the blocks for the two addresses are different. Determine if the addresses are the same, the unit status, the correct block, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX







 

 

 

CCM ADDRESS 2


 


Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX Skip to Question 8

Other __________________________________ Skip to Question 8

No











CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block YYYYYYY? (B)

Yes

No In what block number is CENSUS ADDRESS?


FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 2, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

CCM DUPLICATE ADDRESS


13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other ________________________________ ® Skip to Question 19

No

SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________



16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1, do any other addresses (F2)

in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


19. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________



FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE

STOP – Go to Next Form


Surrounding Block Match/Possible CCM-Census Match/Two Duplicate Census Addresses (P*/DE/DE)


The CCM and Census addresses are possible matches, and the blocks for the two addresses are different. Determine if the addresses are the same, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other ________________________________ ® Skip to Question 8

No


CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? ( A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2 (G3)

and CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 1?

Yes Enter Census ID:

No

7. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No

12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


FIRST CENSUS DUPLICATE ADDRESS

13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other __________________________________® Skip to Question 19

No


SECOND CENSUS ADDRESS

14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19

15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3) CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CENSUS DUPLICATE ADDRESS

19. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other ____________________________________® Skip to Question 25

No





THIRD CENSUS ADDRESS

20. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the

map spot number here:


23. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


24. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE









Unit Status Update and Surrounding Block Match/Possible CCM-Census Match/Two Duplicate Census Addresses (P*/DE/DE)


The CCM and Census addresses are possible matches, the unit status was listed by CCM as something other than occupied or vacant, and the blocks for the two addresses are different. Determine if the addresses are the same, the unit status, the correct block, and if the addresses on the Census list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS


CENSUS ADDRESS 1







XXXXXXX





CENSUS ADDRESS 2








XXXXXXX




CENSUS ADDRESS 3



Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS and CENSUS ADDRESS 1 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS

CENSUS ADDRESS 1

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other ________________________________ ® Skip to Question 8

No


CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 1?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 2 (G3)

and CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 1?

Yes Enter Census ID:

No

7. Is CENSUS ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 1?

CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS?


FIRST CENSUS DUPLICATE ADDRESS

13. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other __________________________________® Skip to Question 19

No


SECOND CENSUS ADDRESS

14. Was there a housing unit at CENSUS ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19



15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


16. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS 2?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


17. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 and (G3) CENSUS ADDRESS 3, do any other addresses in that column refer to the same housing unit as CENSUS ADDRESS 2?

Yes Enter Census ID:

No


18. Is CENSUS ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?



SECOND CENSUS DUPLICATE ADDRESS

19. Do CENSUS ADDRESS 1 and CENSUS ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CENSUS ADDRESS 1

CENSUS ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other ____________________________________® Skip to Question 25

No


THIRD CENSUS ADDRESS

20. Was there a housing unit at CENSUS ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the (D)

same housing unit as CENSUS ADDRESS 3?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the

map spot number here:


23. Look at the Census column of the Housing Unit Reference List. Aside from CENSUS ADDRESS 1 (G3)

and CENSUS ADDRESS 2, do any other addresses in that column refer to the same housing unit

as CENSUS ADDRESS 3?

Yes Enter Census ID:

No


24. Is CENSUS ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE







Surrounding Block Match/Possible CCM-Census Match/Two Duplicate CCM Addresses (P*/DI/DI)


The CCM and Census addresses are possible matches, and the blocks for the two addresses are different. Determine if the addresses are the same, the correct block, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other _____________________________ ® Skip to Question 8

No










CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?

FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

FIRST CCM DUPLICATE ADDRESS

13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other _______________________________® Skip to Question 19

No


SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19


15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS

19. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other _____________________________________® Skip to Question 25

No



























THIRD CCM ADDRESS


20. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the (E)

same housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


23. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No

24. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE










Unit Status Update and Surrounding Block Match/Possible CCM-Census Match/Two Duplicate CCM Addresses (P*/DI/DI)


The CCM and Census addresses are possible matches, the unit status was listed by CCM as something other than occupied or vacant, and the blocks for the two addresses are different. Determine if the addresses are the same, the unit status, the correct block, and if the addresses on the CCM list are the same.


CCM Address(es)


Census Address(es)

Block

MSN

WMSN

TOA

Unit Status

# Units


Block

Census ID

MSN

XXXXXXX







XXXXXXX



CCM ADDRESS 1


CENSUS ADDRESS

XXXXXXX









CCM ADDRESS 2




XXXXXXX









CCM ADDRESS 3




Hello. I am (your name) from the U.S. Census Bureau. Here is my identification. We are checking some addresses in this area as part of the 2010 Census. The questions should only take 3 minutes. This notice explains that your answers are confidential. (Hand the respondent a Confidentiality Notice and allow time for him or her to read it.)


(If you cannot locate the address, ask a neighbor, apartment manager, or mail carrier) I’m trying to find (address). Did or does the house/apartment at (address) ever use a different address?



1. [Go to next question. /Fill question or note from analyst beginning with: Special question: _______________________ (M)

_______________________________________________________________________________________________

_______________________________________________________________________________________________ ]


2. Do CCM ADDRESS 1 and CENSUS ADDRESS refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CENSUS ADDRESS

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 8

Other _____________________________ ® Skip to Question 8

No








CENSUS ADDRESS


3. Was there a housing unit at CENSUS ADDRESS on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CENSUS ADDRESS

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 7

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

______________________________________________________________________ Skip to Question 8


4. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


5. Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same (D)

housing unit as CENSUS ADDRESS?

Yes Enter CCM MSN and WMSN

No Add new map spot to the CCM Block Map ONLY if this address is a housing unit, then enter the map

spot number here:


6. Look at the Census column of the Housing Unit Reference List. Do any other addresses in that column refer to the (G1)

same housing unit as CENSUS ADDRESS?

Yes Enter Census ID:

No


7. Is CENSUS ADDRESS located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS?

FIRST CCM ADDRESS


8. Was there a housing unit at CCM ADDRESS 1 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 1

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 12

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 13


9. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________

______________________________________________________________________


10. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E) housing unit as CCM ADDRESS 1?

Yes Enter Census ID:

No


11. Look at the CCM column of the Housing Unit Reference List. Do any other addresses in that column refer to the same (F1)

housing unit as CCM ADDRESS 1?

Yes Enter CCM MSN and WMSN

No


12. Is CCM ADDRESS 1 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 1?

FIRST CCM DUPLICATE ADDRESS

13. Do CCM ADDRESS 1 and CCM ADDRESS 2 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 2

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 19

Other _______________________________® Skip to Question 19

No


SECOND CCM ADDRESS


14. Was there a housing unit at CCM ADDRESS 2 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 2

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….…………

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 18

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 19


15. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________

16. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same (E)

housing unit as CCM ADDRESS 2?

Yes Enter Census ID:

No


17. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and CCM ADDRESS 3, (F3)

do any other addresses in that column refer to the same housing unit as CCM ADDRESS 2?

Yes Enter CCM MSN and WMSN

No


18. Is CCM ADDRESS 2 located in block XXXXXXX? (B)

Yes

No In what block number is CENSUS ADDRESS 2?


SECOND CCM DUPLICATE ADDRESS

19. Do CCM ADDRESS 1 and CCM ADDRESS 3 refer to the same housing unit? (C1)

Yes a. What is the correct address?

CCM ADDRESS 1

CCM ADDRESS 3

Neither address is correct

What is the correct address? ___________________________________________________

b. What is the correct block? (C2)

XXXXXXX ® Skip to Question 25

Other _____________________________________® Skip to Question 25

No

THIRD CCM ADDRESS


20. Was there a housing unit at CCM ADDRESS 3 on April 1st, 2010? (A)

Yes, and address is correct

Yes, but address needs correction

(Write correct address here): ____________________________________________________________________

No Please describe the status of CCM ADDRESS 3

  • U nder construction (doors, windows, or floors NOT in place)……………………………………….………….

  • Future construction………………………………………………………………………………………………….

Unfit for habitation (condemned or open to the elements) and unoccupied…………………………………..

  • Demolished or burned down………………………………………………………………………………………..

  • Boarded up…………………………………………………………………………………………………..………

Unit used for storage of non-household goods…………………………………………………………….…… Skip to

Empty trailer lot/site or trailer/house has been moved………………………………………………………… Question 24

Group quarters Enter facility name: __________________________________________________

Describe facility: __________________________________________________


_________________________________________________

Business………………………………………………………………………………………………………….

Other Explain what is on the ground; continue on back and draw sketch map if needed

________________________________________________________________________________

Cannot locate Explain what is on the ground; continue on the back and draw a sketch map if needed.


________________________________________________________________­________________________

_____________________________________________________________________ Skip to Question 25


21. How many housing units were at this basic street address on April 1st, 2010? (L)

One

More than one How many? ____________

List all unit designations (e.g., Apt. 12A, 12B, or for several units list ranges of all units,

e.g., Apts. 101-106, 201-206, 301-306) continue in Notes and on the back if necessary:


______________________________________________________________________


______________________________________________________________________


22. Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the (E)

same housing unit as CCM ADDRESS 3?

Yes Enter Census ID:

No


23. Look at the CCM column of the Housing Unit Reference List. Aside from CCM ADDRESS 1 and (F3)

CCM ADDRESS 2, do any other addresses in that column refer to the same housing unit as CCM ADDRESS 3?

Yes Enter CCM MSN and WMSN

No

24. Is CCM ADDRESS 3 located in block XXXXXXX? (B)

Yes

No In what block number is CCM ADDRESS 3?


25. Main source of information you used to fill out questions: (N)

Household member

Building manager or landlord

Proxy

Observation


Notes: _____________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


___________________________________________________________________________________________________________


STOP – Go to Next Form

FOR QC USE ONLY

CL

QC

Correct

QC

Incorrect

QC

CL

QC

OE












File Typeapplication/msword
File TitleNI Question Box
AuthorTony Rosenberger
Last Modified Byrosen319
File Modified2010-06-03
File Created2010-06-03

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