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Draft 1 (3-17-2009)
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OMB No. XXXX-XXXX Approval Expires XX/XX/XXXX
RESPONDENT INFORMATION
U.S. CENSUS BUREAU
R1.
We do not want to miss any people who might have been staying here on April 1.
Were there any additional people that you didn’t mention, for example:
R2.
(Ask or verify) What is your name?
First Name
No
No
No
No
No
Yes
No
MI
Area Code
–
Day
Address of proxy
R3.
Last Name
A.
Unit Status on April 1, 2010
Occupied
Vacant - regular
Vacant - usual home elsewhere
Demolished/burned out/cannot locate
Nonresidential
Empty mobile home/trailer site
Uninhabitable (open to elements,
condemned, under construction)
Duplicate – record ID of Dup. C
Do you or does someone in this household own this (house/apartment/mobile home) with a mortgage or loan,
including home equity loans; own it free and clear; rent it; or occupy it without having to pay rent?
B.
County
Tract
Block
AA
Map Spot
For rent
Rented, not occupied
For sale only
Sold, not occupied
For seasonal, recreational or
occasional use
For migrant workers
Other vacant
Are there any continuation forms for this address?
Yes ➙
D.
What language was the majority of the interview conducted in?
RECORD OF CONTACT
Type
Mo
MOV
F.
CO
PI
G.
REP
REF
H.
L.
J.
I certify that the entries I have made on this questionnaire are
true and correct to the best of my knowledge.
S1.
JIC2
M.
Mo
Day
Outcome
:
a.m.
p.m.
:
a.m.
p.m.
Outcome
Time
Personal
Telephone
Employee ID
S2.
Crew Leader’s initials
CLD number
Month
Hello, I’m (Name) from the U.S. Census Bureau.
(Show ID). Is this (Address)?
S4.
Yes - Continue with question S2.
No - Ask: Can you tell me where to find (Address)?
END INTERVIEW.
I’m here to complete a Census questionnaire for this
address. It should take about 10 minutes. (Hand
respondent an Information Sheet.) The first part explains
that your answers are confidential. I’ll refer to the other
parts later. Did you or anyone in this household live or
stay here on April 1, 2010?
Yes - Continue with question S3.
No - Skip to question S4.
S3.
Day
Time
Telephone
Outcome
Time
Day
K.
CERTIFICATION
Month
:
a.m.
p.m.
Mo
Personal
VDC
JIC1
ZIP Code
Enumerator’s signature
:
a.m.
p.m.
Type
OUTCOME CODES: NV = Left Notice of Visit NC = No Contact RE = Refusal CI = Conducted Interview OT = Other
I.
Other – Specify language number from flashcard ➙
NOTES
Day
Outcome
Time
Personal
Telephone
Spanish
Go to Respondent Information on back page.
Day
I
J
K Personal
E.
English
Number of forms
No
Mo
Street name or rural route address
State
State
➤
APPLY LABEL HERE
Number of people listed on form(s) =
01 - 49 = Total people
00 = Vacant
98 = Delete
99 = POP unknown
UHE
Apartment number
City
C.
If vacant, ask: Which category best
describes this vacant unit as of
April 1, 2010? (Read categories.)
If there is not an address label affixed, or if the address label includes only a location description, ask –
What is the address of this unit?
House number
LCO
–
INTERVIEW SUMMARY
Own with a mortgage or loan (including home equity loans)
Own free and clear (without a mortgage or loan)
Rent
Occupy without payment of rent
H3.
Either
Respondent Type –
Last Name
Do not list any people recorded for this question on the inside pages or on a continuation form.
H2.
Evening
Household member – Lived here on April 1, 2010
Household member – Moved in after April 1, 2010
Neighbor or other proxy
Anyone else?
First Name
–
Unit ID
Last Name
If yes to any category, ask: What is that person’s name?
First Name
Number
Day
Does someone usually live at this
(house/apartment/mobile home), or is this a vacation
or seasonal home?
Usually lives here - Skip to question S5.
Vacation or seasonal home or held for occasional use –
Skip to "Respondent Information" on back page.
USCENSUSBUREAU
(Only ask if no household member lived here on April 1.)
On April 1, was this unit vacant, or occupied by a
different household?
Vacant - Skip to "Respondent Information" on back page.
Occupied by a different household - Using a
knowledgeable respondent, complete this
questionnaire for the Census Day household.
Not a housing unit – Skip to "Respondent Information"
on back page.
S5.
We need to count people where they live and sleep
most of the time.
Please look at list A. It contains examples of
people who should and should not be counted at
this place.
Based on these examples, how many people were
living or staying in this (house/apartment/mobile
home) on April 1?
= Number of people
§p@"¤
793101
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Form D-1(E)(X2)
(3-17-2009)
D-1(E)(X2) - Tone prints in Pantone Process Cyan - 10%, 15%, 25% and 50%
Yes
Yes
Yes
Yes
Yes
ENUMERATOR QUESTIONNAIRE
What is your phone number and best time to call?
D-1(E)(X2) - Base print in Black ink
Babies?
Foster children?
Any other relatives?
Roommates?
Any other nonrelatives?
How about anyone else staying here on April 1
who had no permanent place to live?
Economics and Statistics Administration
➤
H1.
U.S. DEPARTMENT OF COMMERCE
Person 1
First Name
2.
Please look at list B on the Information
Sheet. How is (Name) related to (Read name
of Person 1)?
3.
Mark I
J
K ONE box.
Mark I
J
K ONE box.
I
J
K Person 1
Is (Name)
male or
female?
4.
Age on
April 1, 2010
Male
Female
MI
What was (Name’s) age on
April 1, 2010? What is
(Name’s) date of birth?
Please report babies as age 0
when the child is less than 1
year old.
Print numbers in boxes.
DATE OF BIRTH
Month
Last Name
Day
5.
Please look at List C. Is (Name) of Hispanic, Latino, or
Spanish origin?
Read if necessary:
Examples of another Hispanic, Latino, or Spanish origin
include Argentinean, Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C
6.
Year of birth
MI
Last Name
Son-in-law or
daughter-in-law
Age on
April 1, 2010
Male
Female
Other relative
Roomer or boarder
Housemate
or roommate
DATE OF BIRTH
Month
Day
Unmarried partner
Other nonrelative
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C
Year of birth
Black,
African American,
or Negro
American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native
Hawaiian
Guamanian
or Chamorro
Samoan
MI
Last Name
Son-in-law or
daughter-in-law
Age on
April 1, 2010
Male
Female
Other relative
Roomer or boarder
Housemate
or roommate
DATE OF BIRTH
Month
Day
Unmarried partner
Other nonrelative
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C
Year of birth
Black,
African American,
or Negro
American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Last Name
Age on
April 1, 2010
Male
Female
Other relative
Roomer or boarder
Housemate
or roommate
DATE OF BIRTH
Month
Unmarried partner
Other nonrelative
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C
Day
Year of birth
Person 5
First Name
Last Name
MI
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Son-in-law or
daughter-in-law
Age on
April 1, 2010
Male
Female
Other relative
Roomer or boarder
Housemate
or roommate
DATE OF BIRTH
Month
Day
Unmarried partner
Other nonrelative
Year of birth
Other Pacific Islander — What is that group?
➤
White
Black,
African American,
or Negro
American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Asian — What is that group? C
Other Pacific Islander — What is that group?
➤
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin –
What is that origin? C
Black,
African American,
or Negro
What is the name of the enrolled or principal tribe? C
American
Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Asian — What is that group? C
Other Pacific Islander — What is that group?
➤
Black,
African American,
or Negro
American
What is the name of the enrolled or principal tribe? C
Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other Asian — What is that group? C
Other Pacific Islander — What is that group?
➤
In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No
White
Some other race — What is that group?
In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No
White
Some other race — What is that group?
In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No
➤
MI
Son-in-law or
daughter-in-law
Other Asian — What is that group? C
➤
First Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No
White
Some other race — What is that group?
Person 4
Other Pacific Islander — What is that group?
➤
First Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Other Asian — What is that group? C
➤
Some other race — What is that group?
Person 3
Mark I
J
K all reasons that apply.
➤
First Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Parent-in-law
Does (Name) sometimes live
or stay somewhere else for
any of these reasons? –
Read response categories.
White
Some other race — What is that group?
Person 2
7.
Please look at List D and choose one or more races. For this census, Hispanic origin is not a race.
What is (Name’s) race?
Read if necessary:
Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.
Examples of other Pacific Islander groups include Fijian, Tongan, and so on.
In college housing
In the military
At a seasonal or
second residence
For child custody
In jail or prison
In a nursing home
For another reason
No
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Form D-1(E)(X2) (3-17-2009)
793102
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D-1(E)(X2) - Tone prints in Pantone Process Cyan - 10%, 25% and 50%
Let’s make a list of all those people. Please start with
the name of an owner or renter who was living here
on April 1. Otherwise, start with any adult living here.
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➤
1.
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D-1(E)(X2) - Base print in Black ink
Draft 1 (3-17-2009)
| File Type | application/pdf |
| File Title | D-1(E)(X2)_1_1.g |
| File Modified | 2009-03-17 |
| File Created | 2009-03-17 |