D-1340(EVAL) AFAQ Form (Round 2)
2010 Census Coverage Measurement Final Housing Unit Followup and Address Frame Accuracy & Quality Evaluation
Additional AFAQ Forms for Misgeocoded Operation
Address Frame Accuracy and Quality Evaluation
OMB: 0607-0962
Form D-1340 (EVAL) OMB No. xxxx-xxxx EXPIRES: xx/xx/xxxx <LCO #>.<CLUSTER#>
Surrounding Block Match (M*)
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 |
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|
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|
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 |
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 |
|
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|
|
|
|
|
|
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CCM ADDRESS 2 |
|
|
|||||||
|
|||||||||
XXXXXXX |
|
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|
|
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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 |
|||||||
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XXXXXXX |
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CENSUS ADDRESS 2 |
|||||||
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|||||||||
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XXXXXXX |
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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 |
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 |
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 |
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
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 |
|
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|
|
|
|
XXXXXXX |
|
|
CCM ADDRESS |
|
CENSUS ADDRESS 1 |
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XXXXXXX |
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|
CENSUS ADDRESS 2 |
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XXXXXXX |
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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 |
|
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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 |
(Continued)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | NI Question Box |
| Author | Tony Rosenberger |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |
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