Various Demographic Area Pretesting Activities

Census Household Form

Census Household Form

1. START HERE

Did your household recently move?

No, did not move -- You may use this form to provide your answers OR go to www.census.gov.

Moved on or before Census Day (June 1, 2013) – You may use this form to provide your answers OR go to www.census.gov.

Moved AFTER Census Day (June 1, 2013) – Go to www.census.gov to provide your answers. If you cannot go online, use this form and provide your previous address in Question 11.

2. HOW TO FILL OUT THIS FORM:

Provide information for:

• Anyone who, on Census Day (June 1, 2013), was living or staying at the address printed on this form.

• Anyone who sleeps most of the time at this address, even if they do not live here.

1. The Census must count every person living in the United States on Census day (June 1, 2013), where they live and sleep most of the time. How many people were living or staying at this address on June 1, 2013?

= Number of people for Question 1

2. Were there any additional people staying here on Census Day who you did not include in Question 1?

	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?
	Anyone else staying here who had no permanent place to live?
	No additional people

Be sure to provide information inside this form about everyone you listed in Questions 1 and 2.

3. What is your telephone number?

4. Is this house, apartment, or mobile home—Mark  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?

Answer for the owner or leaseholder if you rent space from someone who also lives here.

5. Is the residence to which this form was sent vacant for any reason, such as being for rent or under renovation, or is it a seasonal home where no one lives for the entire year?

Yes – Call 888- 123-5678 to provide additional information about this vacant residence.

No – Continue with the form on Page 2

Person 1

6. Please provide information for each person counted in Questions 1 and 2. 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.

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

First Name

Middle Name

Last Name

7. What is Person 1’s sex? Mark  ONE box.

Male

Female

8. 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 June 1, 2013 Month Day Year

9. What is Person 1’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 10

10. In the past year, did Person 1 sometimes live or stay somewhere else?

No – Skip to Question 13

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

11. If you marked yes in Question 10, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

12. Where did Person 1 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 11

Some other place

13. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 2

1. What is Person 2’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 2 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 2’s sex? Mark  ONE box.

Male

Female

4. What is Person 2’s age and what is Person 2’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 June 1, 2013 Month Day Year

5. What is Person 2’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 2 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 2 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 3

1. What is Person 3’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 3 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 3’s sex? Mark  ONE box.

Male

Female

4. What is Person 3’s age and what is Person 3’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 June 1, 2013 Month Day Year

5. What is Person 3’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 3 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 3 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 4

1. What is Person 4’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 4 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 4’s sex? Mark  ONE box.

Male

Female

4. What is Person 4’s age and what is Person 4’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 June 1, 2013 Month Day Year

5. What is Person 4’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 4 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 4 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 5

1. What is Person 5’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 5 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 5’s sex? Mark  ONE box.

Male

Female

4. What is Person 5’s age and what is Person 5’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 June 1, 2013 Month Day Year

5. What is Person 4’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 5 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 5 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 6

1. What is Person 6’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 6 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 6’s sex? Mark  ONE box.

Male

Female

4. What is Person 6’s age and what is Person 6’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 June 1, 2013 Month Day Year

5. What is Person 6’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 6 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 6 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

 If more people were counted in Question 1 or 2, continue.

Person 7

1. What is Person 7’s name? Print name below.

First Name

Middle Name

Last Name

2. How is Person 7 related to Person 1? Mark  ONE box.

Opposite-sex husband/wife/spouse Grandchild

Opposite-sex unmarried partner Parent-in-law

Same-sex husband/wife/spouse Son-in-law or

Same-sex unmarried partner daughter-in-law

Biological son or daughter Other relative

Adopted son or daughter Roomer or boarder

Stepson or stepdaughter Housemate or

Brother or sister roommate

Father or mother Foster child

Other nonrelative

3. What is Person 7’s sex? Mark  ONE box.

Male

Female

4. What is Person 7’s age and what is Person 7’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 June 1, 2013 Month Day Year

5. What is Person 7’s race or origin? Mark X one or more boxes AND write in the specific race(s) or origin(s).

White – For example, German, Irish, Lebanese, Egyptian, and so on

Black or African Am. – For example, African American, Haitian, Nigerian and so on

Hispanic, Latino or of Spanish origin – For example, Mexican, Mexican Am., Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

American Indian or Alaska Native – For example, Navajo, Mayan, Tlingit and so on

Asian – For example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian and so on

Native Hawaiian or Other Pacific Islander – For example, Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan and so on

Some Other Race or origin

 Continue to Question 7

6. In the past year, did Person 7 sometimes live or stay somewhere else?

No – Skip to Question 9

Yes – If there is more than one place, mark the OTHER place where this person stays most of the time

Mark  all that apply

In college housing

In the military

For a job or business

With a parent or grandparent

At a second or seasonal residence

With a friend

For another reason

Because of a move:

What date? ____/____/_______

7. If you marked yes in Question 6, please provide the address of the other place where this person sometimes lived or stayed most of the time.

Street Address

Apartment Number

City

State

Zip Code

8. Where does Person 7 stay most of the time?

The address printed on the back of this questionnaire

The address or location listed in Question 7

Some other place

9. On the night of June 1, 2013, did this person stay in a facility such as a jail, shelter, or nursing home or some other kind of facility?

No

Yes – Provide the facility name, street address, city and state below

Facility Name

Street Address

City

State

RESIDENT AT:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

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