DA-1 2012 National Census Test (paper questionnaire)

Draft 4 4-30-2012

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DRAFT

Attachment A
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

Person 7

Last Name

First Name

https://respond.census.gov/nct

MI

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

Use a blue or black pen.

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

Start here
Sex

Age on September 5, 2012

Month

Male
Female

Person 8

Last Name

Related to Person 1?

Date of Birth
Day

Year

Yes
No

First Name

MI

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

Last Name

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

First Name

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

Age on September 5, 2012

Month

Male
Female

Person 9

Related to Person 1?

Date of Birth
Day

Year

• 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 September 5, 2012.
• 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.

Yes
No

Last Name

First Name

U.S. CENSUS BUREAU

2012 National Census Test

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.

MI

MI

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

Female

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 September 5, 2012

Month

Day

Year of birth

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

Date of Birth
Month

Male

Day

Year

Female

➞

Person 10

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

Related to Person 1?
Yes

• If someone who has no permanent place to stay is staying
here on September 5, 2012, count that person. Otherwise,
he or she may be missed in the census.

No

Last Name

First Name

MI

1. How many people were living or staying in this house,

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

apartment, or mobile home on September 5, 2012?
Sex

Age on September 5, 2012

Month

Male

Day

Year

Female

Person 11

Sex

Last Name

Age on September 5, 2012

First Name

Day

Year

Male

Age on September 5, 2012

First Name

Related to Person 1?

Day

Year

No

Female

FOR OFFICIAL USE ONLY

Thank you for completing the
2012 National Census Test.

JIC1

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?

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 xxxx-xxxx, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project xxxx-xxxx" as the subject.

Yes

don’t understand an answer.
Area Code + Number
–

➞

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

Some other race or origin — Print race(s) or origin(s). C

–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form

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American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

4. What is your telephone number? We may call if we

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

JIC2

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

3. Is this house, apartment, or mobile home —

TDD — Telephone display device for the hearing impaired. Call 1-800-582-8330 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

MI

Date of Birth
Month

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 1-800-972-5650 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.

Yes
No

Last Name

September 5, 2012 that you did not include in Question 1?
Mark I
J
K all that apply.

Related to Person 1?

Date of Birth
Month

2. Were there any additional people staying here

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 E 10th Street
Jeffersonville, IN 47132-0001

MI

Female

Sex

Yes
No

Male

Person 12

Number of people =

Related to Person 1?

Date of Birth

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DA-1

(4-30-2012)

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

DA-1 - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
DA-1 - Base prints in BLACK

➞

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Age on September 5, 2012

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write in the specific race(s) or origin(s).
Sex

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Last Name

Last Name

First Name

MI

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

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

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

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

Female

Male

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 September 5, 2012

Month

Day

Female

Male

Year of birth

Age on September 5, 2012

Month

Day

Fold Line ➞

write in the specific race(s) or origin(s).

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

Female

Male

Age on September 5, 2012

Month

Day

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

write in the specific race(s) or origin(s).

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

Female

Male

Month

Day

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

Year of birth

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

write in the specific race(s) or origin(s).

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 September 5, 2012

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

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

Year of birth

MI

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

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

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

Year of birth

First Name

MI

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

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

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.

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

➜

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

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

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

Last Name

First Name

MI

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

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

1. Print name of Person 6

Last Name

First Name

MI

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

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

1. Print name of Person 5

1. Print name of Person 4

Last Name

First Name

Male

Attachment A

Age on September 5, 2012

Month

Day

Year of birth

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

write in the specific race(s) or origin(s).

write in the specific race(s) or origin(s).

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

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

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

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

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

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

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

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

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

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

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

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

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

➜

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

➜

If more people were counted in Question 1 on the front page,
continue with Person 5.

➜

If more people were counted in Question 1 on the front page,
continue with Person 6.

➜

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

If more than six people were counted in Question 1 on
the front page, turn the page and continue.
Form DA-1
(4-30-2012)

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DA-1 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
DA-1 - Base prints BLACK

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DRAFT
1. Print name of Person 3

1. Print name of Person 2

Fold Line ➞

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1. Print name of Person 3

Last Name

Last Name

Last Name

First Name

First Name

MI

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

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

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

Female

Male

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 September 5, 2012

Month

Day

Female

Male

Year of birth

Age on September 5, 2012

Month

Day

Fold Line ➞

write in the specific race(s) or origin(s).

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

Female

Male

Age on September 5, 2012

Month

Day

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

write in the specific race(s) or origin(s).

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

Female

Male

Month

Day

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

Year of birth

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

write in the specific race(s) or origin(s).

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 September 5, 2012

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

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

Year of birth

MI

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

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

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

Year of birth

First Name

MI

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

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

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.

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

➜

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

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

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

Last Name

First Name

MI

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

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

1. Print name of Person 6

Last Name

First Name

MI

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

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
Male

1. Print name of Person 4

Attachment A

Age on September 5, 2012

Month

Day

Year of birth

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

write in the specific race(s) or origin(s).

write in the specific race(s) or origin(s).

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

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

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

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

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

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

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

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

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

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

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

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

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

➜

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

➜

If more people were counted in Question 1 on the front page,
continue with Person 5.

➜

If more people were counted in Question 1 on the front page,
continue with Person 6.

➜

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

If more than six people were counted in Question 1 on
the front page, turn the page and continue.
Form DA-1
(4-30-2012)

Fold Line ➞

Fold Line ➞
DA-1 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
DA-1 - Base prints BLACK

Fold Line ➞

1. Print name of Person 2

DRAFT
1. Print name of Person 5

Fold Line ➞

Fold Line ➞

1. Print name of Person 3

Last Name

First Name

MI

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

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

Female

Male

Age on September 5, 2012

Month

Day

Female

Male

Year of birth

Age on September 5, 2012

Month

Day

Fold Line ➞

write in the specific race(s) or origin(s).

➜

Female

Male

Age on September 5, 2012

Month

Day

Female

Age on September 5, 2012

Male

Month

Day

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.

Year of birth

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

write in the specific race(s) or origin(s).

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

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

Year of birth

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

write in the specific race(s) or origin(s).

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

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.

Year of birth

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

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

MI

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

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

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.

First Name

MI

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

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

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.

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

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

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

Age on September 5, 2012

Month

Day

Year of birth

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

write in the specific race(s) or origin(s).

write in the specific race(s) or origin(s).

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

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

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

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

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

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

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

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

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

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

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

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

Some other race or origin — Print race(s) or origin(s). C

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

➜

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

➜

If more people were counted in Question 1 on the front page,
continue with Person 5.

➜

Attachment A

Last Name

First Name

MI

DRAFT

1. Print name of Person 6

Last Name

First Name

MI

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

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
Male

Last Name

Last Name

First Name

1. Print name of Person 5

1. Print name of Person 4

If more people were counted in Question 1 on the front page,
continue with Person 6.

➜

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

If more than six people were counted in Question 1 on
the front page, turn the page and continue.
Form DA-1
(4-30-2012)

Fold Line ➞

Fold Line ➞
DA-1 - Pantone PROCESS CYAN (10%, 25%, 50% and 100%)
DA-1 - Base prints BLACK

Fold Line ➞

1. Print name of Person 2

Draft 4 4-30-2012

Fold line

DRAFT

➞

Fold line

➞

Attachment A
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

Person 7

Last Name

First Name

https://respond.census.gov/nct

MI

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

Use a blue or black pen.

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

Start here
Sex

Age on September 5, 2012

Month

Male
Female

Person 8

Last Name

Related to Person 1?

Date of Birth
Day

Year

Yes
No

First Name

MI

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

Last Name

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

First Name

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

Age on September 5, 2012

Month

Male
Female

Person 9

Related to Person 1?

Date of Birth
Day

Year

• 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 September 5, 2012.
• 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.

Yes
No

Last Name

First Name

U.S. CENSUS BUREAU

2012 National Census Test

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.

MI

MI

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

Female

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 September 5, 2012

Month

Day

Year of birth

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

Date of Birth
Month

Male

Day

Year

Female

➞

Person 10

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

Related to Person 1?
Yes

• If someone who has no permanent place to stay is staying
here on September 5, 2012, count that person. Otherwise,
he or she may be missed in the census.

No

Last Name

First Name

MI

1. How many people were living or staying in this house,

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

apartment, or mobile home on September 5, 2012?
Sex

Age on September 5, 2012

Month

Male

Day

Year

Female

Person 11

Sex

Last Name

Age on September 5, 2012

First Name

Day

Year

Male

Age on September 5, 2012

First Name

Related to Person 1?

Day

Year

No

Female

FOR OFFICIAL USE ONLY

Thank you for completing the
2012 National Census Test.

JIC1

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?

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 xxxx-xxxx, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project xxxx-xxxx" as the subject.

Yes

don’t understand an answer.
Area Code + Number
–

➞

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

Some other race or origin — Print race(s) or origin(s). C

–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form

Fold line

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

4. What is your telephone number? We may call if we

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

JIC2

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

3. Is this house, apartment, or mobile home —

TDD — Telephone display device for the hearing impaired. Call 1-800-582-8330 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

MI

Date of Birth
Month

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 1-800-972-5650 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.

Yes
No

Last Name

September 5, 2012 that you did not include in Question 1?
Mark I
J
K all that apply.

Related to Person 1?

Date of Birth
Month

2. Were there any additional people staying here

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 E 10th Street
Jeffersonville, IN 47132-0001

MI

Female

Sex

Yes
No

Male

Person 12

Number of people =

Related to Person 1?

Date of Birth

Fold line

➞

DA-1

(4-30-2012)

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

DA-1 - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
DA-1 - Base prints in BLACK

➞

Fold Line

Age on September 5, 2012

Fold Line

write in the specific race(s) or origin(s).
Sex

Draft 4 4-30-2012

Fold line

➞

Fold line

DRAFT

➞

Attachment A
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

Person 7

Last Name

First Name

https://respond.census.gov/nct

MI

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

Use a blue or black pen.

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

Start here
Sex

Age on September 5, 2012

Month

Male
Female

Person 8

Last Name

Related to Person 1?

Date of Birth
Day

Year

Yes
No

First Name

MI

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

Last Name

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

First Name

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

Age on September 5, 2012

Month

Male
Female

Person 9

Related to Person 1?

Date of Birth
Day

Year

• 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 September 5, 2012.
• 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.

Yes
No

Last Name

First Name

U.S. CENSUS BUREAU

2012 National Census Test

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.

MI

MI

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

Female

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 September 5, 2012

Month

Day

Year of birth

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

Date of Birth
Month

Male

Day

Year

Female

➞

Person 10

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

Related to Person 1?
Yes

• If someone who has no permanent place to stay is staying
here on September 5, 2012, count that person. Otherwise,
he or she may be missed in the census.

No

Last Name

First Name

MI

1. How many people were living or staying in this house,

White — Print origin(s), for example, German, Irish, Lebanese, Egyptian, and so on. C

Black or African Am. — Print origin(s), for example, African American, Haitian,
Nigerian, and so on. C

apartment, or mobile home on September 5, 2012?
Sex

Age on September 5, 2012

Month

Male

Day

Year

Female

Person 11

Sex

Last Name

Age on September 5, 2012

First Name

Day

Year

Male

Age on September 5, 2012

First Name

Related to Person 1?

Day

Year

No

Female

FOR OFFICIAL USE ONLY

Thank you for completing the
2012 National Census Test.

JIC1

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?

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 xxxx-xxxx, U.S. Census
Bureau, AMSD-3K138, 4600 Silver Hill Road, Washington, DC 20233. You may e-mail comments to
; use "Paperwork Project xxxx-xxxx" as the subject.

Yes

don’t understand an answer.
Area Code + Number
–

➞

Asian — Print origin(s), for example, Asian Indian, Chinese, Filipino, Japanese, Korean,
Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. C

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

Some other race or origin — Print race(s) or origin(s). C

–

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
Form

Fold line

American Indian or Alaska Native — Print name of enrolled or principal tribe(s),
for example, Navajo, Mayan, Tlingit, and so on. C

4. What is your telephone number? We may call if we

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

JIC2

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

3. Is this house, apartment, or mobile home —

TDD — Telephone display device for the hearing impaired. Call 1-800-582-8330 between
8:00 a.m. and 9:00 p.m., 7 days a week. The telephone call is free.

MI

Date of Birth
Month

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 1-800-972-5650 between 8:00 a.m. and 9:00 p.m.,
7 days a week. The telephone call is free.

Yes
No

Last Name

September 5, 2012 that you did not include in Question 1?
Mark I
J
K all that apply.

Related to Person 1?

Date of Birth
Month

2. Were there any additional people staying here

If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 E 10th Street
Jeffersonville, IN 47132-0001

MI

Female

Sex

Yes
No

Male

Person 12

Number of people =

Related to Person 1?

Date of Birth

Fold line

➞

DA-1

(4-30-2012)

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

DA-1 - Prints Pantone PROCESS CYAN (10%. 20%, 25%,50% and 100%)
DA-1 - Base prints in BLACK

➞

Fold Line

Age on September 5, 2012

Fold Line

write in the specific race(s) or origin(s).
Sex