D-1 X5 2010 Experimental Questionnaire Version 5 (Combined Race

Draft 1 (2-27-2009)

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U.S. DEPARTMENT OF COMMERCE

Use this section to complete information for the rest of the people you counted in Question 1 on the front
page. We may call for additional information about them.

5.
Last Name

First Name

MI

Use a blue or black pen.

Start Here
Sex

Age on April 1, 2010

Date of Birth
Month

Male
Female

Day

Sex

Last Name

Age on April 1, 2010
Male
Female

Year

What is Person 1’s name? Print name below.
Last Name

The Census must count every person living in the
United States on April 1, 2010.

Yes
No

Person 9

MI

First Name

Date of Birth
Month

Day

Last Name

Related to Person 1?
Year

Yes
No

Age on April 1, 2010

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Male
Female

The Census Bureau also conducts counts in institutions
and other places, so:

7.

What is Person 1’s age and what is Person 1’s date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Month
Day
Year of birth
Age on April 1, 2010

8.

What is Person 1’s race or origin? Mark K
J one or more boxes.
I

Related to Person 1?
Yes
No

• If someone who has no permanent place to stay is staying
here on April 1, 2010, count that person. Otherwise,
he or she may be missed in the census.

MI

1.
Age on April 1, 2010
Male
Female

Person 11

Sex

Month

Last Name

Age on April 1, 2010

Sex

Year

U.S. Census Bureau

Yes
No

Date of Birth
Month
Day

Year

2.

MI

Related to Person 1?
Yes
No

TDD — Telephone display device for the hearing impaired. Call 1-866-783-2010 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.

JIC1

Asian Indian
Chinese
Filipino

4.

Respondents are not required to respond to any information collection unless it displays a valid approval number
from the Office of Management and Budget.

Is this house, apartment, or mobile home —
Mark K
J ONE box.
I

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Some other race or origin — Print race or origin. C

What is your telephone number? We may call if we
don’t understand an answer.
Area Code + Number
–

JIC2

Japanese
Korean
Vietnamese

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

Owned by you or someone in this household with a
mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and
clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

The U.S. Census Bureau estimates that, for the average household, this form will take about 10 minutes to
complete, including the time for reviewing the instructions and answers. Send comments regarding this burden
estimate or any other aspect of this burden to: Paperwork Reduction Project 0607-0919-C, U.S. Census Bureau,
AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project 0607-0919-C" as the subject.

Yes
No

FOR OFFICIAL USE ONLY

Thank you for completing your
official 2010 Census form.

3.

¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1-866-943-2010 entre
las 8:00 a.m. y 9:00 p.m., 7 días a la semana. La llamada telefónica es gratis.

MI

Were there any additional people staying here
April 1, 2010 that you did not include in Question 1?
Mark I
J
K all that apply.
Children, such as newborn babies or foster children
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in baby sitters
People staying here temporarily
No additional people

If you need help completing this form, call 1-866-948-2010 between 8:00 a.m. and 9:00 p.m., 7 days a week.
The telephone call is free.

Related to Person 1?
Year

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

Number of people =

1201 East 10th Street

First Name

Date of Birth
Month
Day

How many people were living or staying in this house,
apartment, or mobile home on April 1, 2010?

National Processing Center

First Name

Last Name

Age on April 1, 2010
Male
Female

Day

Related to Person 1?

Jeffersonville, IN 47132

Male
Female

Person 12

Date of Birth

Female

White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

The Census must also include people without a permanent
place to stay, so:

If your enclosed postage-paid envelope is missing, please mail your completed form to:
Sex

Male

• Do not count anyone in a nursing home, jail, prison,
detention facility, etc., on April 1, 2010.

MI

First Name

Last Name

What is Person 1’s sex? Mark K
J ONE box.
I

–

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX.
Form D-1(X5) (2-27-2009)

§p("¤
790701
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➜

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

USCENSUSBUREAU
040401

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D-1(X5) – Prints Pantone PROCESS Cyan (10%, 20%, 25%, 50%, and 100%)
D-1(X5)- Base prints in BLACK

U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU

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Person 10

Year

MI

6.

• Do not count anyone living away either at college or in the
Armed Forces.

First Name

Date of Birth
Month
Day

First Name

• Count all people, including babies, who live and sleep here
most of the time.

• Leave these people off your form, even if they will return to
live here after they leave college, the nursing home, the
military, jail, etc. Otherwise, they may be counted twice.
Sex

Please provide information for each person living here. Start with
a person living here who owns or rents this house, apartment, or
mobile home. If the owner or renter lives somewhere else, start
with any adult living here. This will be Person 1.

Related to Person 1?

Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our guidelines.

Person 8

U.S. CENSUS BUREAU

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Person 7

Economics and Statistics Administration

This is the official form for all the people at this address. It
is quick and easy, and your answers are protected by law.

Last Name

First 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
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

J
K ONE box.
3. What is this person’s sex? Mark I

Month

Day

MI

Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Male

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010

First Name

2. How is this person related to Person 1? Mark I
J
K ONE box.
Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

Female

4. What is this person’s age and what is this person’s date of birth?
Year of birth

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

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Last Name

Last Name

J
K ONE box.
2. How is this person related to Person 1? Mark I

1. Print name of Person 5

1. Print name of Person 4

First Name

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild
Male

4. What is this person’s age and what is this person’s date of birth?

Last Name

Last Name

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

Female

1. Print name of Person 6

Female

First Name
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Brother or sister
Father or mother
Grandchild

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.
Male

4. What is this person’s age and what is this person’s date of birth?

First Name

MI

2. How is this person related to Person 1? Mark I
J
K ONE box.

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
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

3. What is this person’s sex? Mark I
J
K ONE box.

Female

Male

4. What is this person’s age and what is this person’s date of birth?

Female

4. What is this person’s age and what is this person’s date of birth?

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010
Month
Day
Year of birth

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010
Month
Day
Year of birth

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010
Month
Day
Year of birth

Please report babies as age 0 when the child is less than 1 year old.
Print numbers in boxes.
Age on April 1, 2010
Month
Day
Year of birth

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

5. What is this person’s race or origin? Mark I
J
K one or more boxes.

White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

White
Black, African Am., or Negro
Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Mexican, Mexican Am., Chicano
Puerto Rican
Cuban
Other Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

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

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

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

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

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

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

White
Black, African Am., or Negro

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Some other race or origin — Print race or origin. C

Some other race or origin — Print race or origin. C

Some other race or origin — Print race or origin. C

Some other race or origin — Print race or origin. C

Some other race or origin — Print race or origin. C

➜ If more people were counted in Question 1 on the front

➜ If more people were counted in Question 1 on the front

➜ If more people were counted in Question 1 on the front

➜ If more people were counted in Question 1 on the front

➜ If more than six people were counted in Question 1 on

page, continue with Person 3.

page, continue with Person 5.

page, continue with Person 4.

page, continue with Person 6.

the front page, turn the page and continue.
Form D-1(X5) (2-24-2009)

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790702

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➜ If more people
live here, turn
the page and
continue.

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1. Print name of Person 3

D-1(X5) - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)

1. Print name of Person 2

Male

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D-1(X5) - Base prints BLACK

Draft 1 (2-27-2009)