D-1 X13 2010 Experimental Questionnaire Version 13 (Coverage)

Generic Clearance for 2010 Census Program for Evaluations & Experiments (CPEX)

D-1(X13)_1_2_D3_031209

201 Census Alternative Questionnaire Experiment

OMB: 0607-0952

Document [pdf]

Download: pdf | pdf

Draft 3 (3-12-2009)

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

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Use a blue or black pen.

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

• Count all people, including babies, who live and sleep here most of the time.
The Census Bureau also conducts counts in institutions and other places, so:
Respondents are not required to respond to any information collection unless it displays a
valid approval number from the Office of Management and Budget.

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.

¿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.

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.

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.

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

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

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

• Do not count anyone living away either at college or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention facility, etc., on April 1, 2010.
• 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.
The Census must also include people without a permanent place to stay, so:
• 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.

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

2. 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

3. Is this house, apartment, or mobile home — Mark I
J
K ONE box.
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?

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

–

OMB No. XXXX-XXXX-X: Approval Expires XX/XX/XXXX

Form D-1(X13) (3-12-2009)

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791512

D-1(X13) - Page 1 and 12 Overlay 1, - Prints Pantone Process Cyan, 10%, 20%, 25%, 50% and 100%

USCENSUSBUREAU

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791501
D-1(X13), Page 1 and 12 Base copy - Prints Black ink

Fold line

Draft 3 (3-12-2009)

Person 1

10. Does Person 1 sometimes live or stay somewhere else?
No ➞SKIP to Person 2, if more people live here.

5. Please provide information for each person living here. Start with a

In college housing
In the military
For a job or business
For child custody

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

Person 10

Yes — Mark I
J
K all that apply.

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.

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.

At a seasonal or second residence
In jail or prison
In a nursing home
For another reason

Last Name

Sex

Age on April 1, 2010

11. IF you marked yes to Question 10, please provide the full address of

First Name

Day

Related to Person 1?
Year

Yes
No

Female

House Number

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

Date of Birth
Month

Male

the other place where Person 1 sometimes lives or stays:

Male

First Name

Person 11

Female

Street Name

Last Name

First Name

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

➜ NOTE: Please answer BOTH Question 8 about Hispanic origin and
Question 9 about race. For this census, Hispanic origins are not races.

9. What is Person 1’s race? Mark I
J
K one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

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

Some other race — Print race. C
791502

➜ Continue to Question 10.

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

Date of Birth
Month

Apartment Number

Day

Related to Person 1?
Year

Male

Yes

Female

Rural Route Address

Person 12

8. Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

Age on April 1, 2010

Sex

First Name

Last Name

City

Age on April 1, 2010

Sex

Date of Birth
Month

State

ZIP Code

Day

Related to Person 1?
Year

Male

Yes

Female

Person 13

County

First Name

Last Name

➜ NOTE: If there is no street address or if this is a facility, please print a
description in the boxes below.

Sex

Age on April 1, 2010

Date of Birth
Month

12. Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 11
Both places equally
Some other place

13. On April 1, 2010, where was Person 1 staying?
The address printed on the back of this questionnaire
The address or location you listed in Question 11
Some other place

➜ If more people were counted in Question 1, continue with

Day

Related to Person 1?
Year

Male

Yes

Female

Person 14
Last Name

Sex

First Name

Age on April 1, 2010

Date of Birth
Month

Day

Related to Person 1?
Year

Male

Yes

Female

No
FOR OFFICIAL USE ONLY

Thank you for completing your official
2010 Census form.

JIC1

JIC2

Person 2.
2

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791502

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791511

D-1(X13), Page 2 & 11 Base copy - Prints Black ink
D-1(X13) - Pages 2 & 11 - Prints Pantone Process Cyan, 10%, 25%, 50% and 100%

Draft 3 (3-12-2009)

Fold line

1. Print name of

Person 9

No ➞SKIP to the next person, if more people live here.

Last Name

In college housing
In the military
For a job or business
For child custody

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.

7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.
Yes — Mark I
J
K all that apply.

At a seasonal or second residence
In jail or prison
In a nursing home
For another reason

First Name

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

8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number

Street 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.
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
Month
Day
Year of birth

Apartment Number

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

City

State

ZIP Code

City

State

ZIP Code

County

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

6. What is this person’s race? Mark I
J
K one or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

➜ NOTE: If there is no street address or if this is a facility, please print a
description in the boxes below.

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

9. Where does this person live or stay most of the time?
The address or location you listed in Question 8
The address printed on the back of this questionnaire
Both places equally
Some other place

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

➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.

9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place

10. On April 1, 2010, where was this person staying?

10. On April 1, 2010, where was this person staying?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place

Some other race — Print race. C

➜ Continue to Question 7.

➜ If more people were counted in Question 1 on the front page,
continue with Person 10.

Apartment Number

5. Is this person of Hispanic, Latino, or Spanish origin?

County

➜ Continue to Question 7.

Street Name

Question 6 about race. For this census, Hispanic origins are not races.

5. Is this person of Hispanic, Latino, or Spanish origin?

Some other race — Print race. C

House Number

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

Question 6 about race. For this census, Hispanic origins are not races.

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

the other place where this person sometimes lives or stays:

Rural Route Address

➜ NOTE: Please answer BOTH Question 5 about Hispanic origin and

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

8. IF you marked yes to Question 7, please provide the full address of

Female

Rural Route Address

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

At a seasonal or second residence
In jail or prison
In a nursing home
For another reason

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

In college housing
In the military
For a job or business
For child custody

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

Female

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

Person 2

Last Name

Yes — Mark I
J
K all that apply.

First Name

Male

1. Print name of

7. Does this person sometimes live or stay somewhere else?

The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place

➜ If more people were counted in Question 1 on the front page,
continue with Person 3.

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791510

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791503

D-1(X-13), Page 3 & 10 Base copy - Prints Black ink
Fold line

D-1(X13) - Page 3 & 10 Overlay 1, - Prints Pantone Process Cyan, 10%, 25%, 50%, and 100%

Fold line

Draft 3 (3-12-2009)

1. Print name of

Person 3

7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.

Last Name
First Name

Yes — Mark I
J
K all that apply.
In college housing
In the military
For a job or business
For child custody

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.
Male

At a seasonal or second residence
In jail or prison
In a nursing home
For another reason

8. IF you marked yes to Question 7, please provide the full address of
the other place where this person sometimes lives or stays:
House Number

Street Name

1. Print name of

7. Does this person sometimes live or stay somewhere else?
No ➞SKIP to the next person, if more people live here.

Last Name

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?

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

Apartment Number

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

City

State

ZIP Code

State

ZIP Code

6. What is this person’s race? Mark I
J
K one or more boxes.
➜ NOTE: If there is no street address or if this is a facility, please print
a description in the boxes below.

9. Where does this person live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 8
Both places equally
Some other place

The address printed on the back of this questionnaire
The address or location you listed in Question 8
Some other place

➜ If more people were counted in Question 1 on the front page,
continue with Person 4.

§p0%¤
791504

City

County

White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled or
principal tribe. C

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