The American Community Survey

Attachment R

DRAFT 1 -- 7-14-2011
FORM ACS-290B(GQ) (8-1-2011)

U.S. DEPARTMENT OF COMMERCE

1. GQ Name

Economics and Statistics Administration
U.S. CENSUS BUREAU

2. GQ Control Number

SURVEY PACKAGE CONTROL LIST FOR
SPECIAL SWORN STATUS (SSS)
INDIVIDUALS

3. SSS Name
4. SSS Phone Number

AMERICAN COMMUNITY SURVEY
GROUP QUARTERS

NOTE – Please return this form to the Field Representative who picks up the survey package.
Sample Resident Name

Date questionnaire –
Distributed Collected

(a)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Month

Remarks

(c)

(b)
Day

Month

Day

(d)