Decennial Language Research

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

2015 National Census Test

U.S. CENSUS BUREAU

Please provide your 13-digit Census ID:
Who should be listed on this form?

•

Include yourself if you have not been counted in the 2015 National Census Test.

•

Include anyone else who was living with you on April 1, 2015 who has not yet been counted.

•

Include family members, babies, nonrelatives, and anyone else who lives and sleeps at your address most of the time and has not been counted.

1. What was the physical address of the place you were living or staying on April 1, 2015? Please do not provide a PO Box address. If
you have more than one residence, provide the address of the place where you live most of the time.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Apt/Unit (For example: "Apt. A" or "Lot 3")

Rural Route Address

County/Township/Parish

City

State

ZIP Code

2. How many people were living or staying in this house, apartment, or mobile home on April 1, 2015?
Number of people =

3. Were there any additional people staying here April 1, 2015 that you did not include in Question 2?
Mark ✗ 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

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?

5.

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

–

Form DY-2N (11-4-2014)

–

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

Person 1
6.

10. Does Person 1 sometimes live or stay somewhere else?
No

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.

SKIP to Person 2, if more people live here.

Yes — Mark ✗ all that apply.

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

➤

MI

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

11. If you marked yes to Question 10, please provide the full address of
the other place where Person 1 sometimes lives or stays.

Last Name

Address Number (For example: 5007)

7.

What is Person 1’s sex? Mark ✗ ONE box.
Male

8.

9.

Street Name (For example: N Maple Ave)

Female

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, 2015

Apt/Unit (For example: "Apt. A" or "Lot 3")

What is Person 1’s race or origin? — Mark ✗ one or more boxes AND
enter the specific race(s) or origin(s).

Rural Route Address

White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

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

ZIP Code

County

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

➜

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

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

12. Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

The address or location you listed in Question 11
Both places equally
Some other place

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

13. On April 1, 2015, 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

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

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

➜ Continue to Question 10

2

1.

Person 2

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 3.

Continue to Question 6.

3

1.

Person 3

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 4.

Continue to Question 6.

4

1.

Person 4

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 5.

Continue to Question 6.

5

1.

Person 5

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 6.

Continue to Question 6.

6

1.

Person 6

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 7.

Continue to Question 6.

7

1.

Person 7

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 8.

Continue to Question 6.

8

1.

Person 8

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 9

Continue to Question 6.

9

1.

Person 9

Print name of
First Name

6.

Does this person sometimes live or stay somewhere else?

MI

No

➤

SKIP to the next Person, if more people live here.

Yes —Mark ✗ all that apply
Last Name

2.

How is this person 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 daughter-in-law

Same-sex unmarried partner

Other relative

Biological son or daughter

Roomer or boarder

Adopted son or daughter

Housemate or roommate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

7.

In college housing

At a seasonal or second residence

In the military

In jail or prison

For a job or business

In a nursing home

For child custody

For another reason

If you marked yes to Question 6, please provide the full address of
the other place where this person sometimes lives or stays.
Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

Father or mother

3.

What is this person’s sex? Mark ✗ ONE box
Male

4.

Female
Apt./Unit (For example: "Apt A" or "Lot 3")

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
Print numbers in boxes.
less than 1 year old.
Month
Day
Year of birth
Age on April 1, 2015

Rural Route Address

5. What is this person’s race or origin? —Mark

✗ one or more boxes

AND enter the specific race(s) or origin(s).
White — Print origin(s), for example, German, Irish, English, Italian,
Polish, French, and so on.

City

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

State

ZIP Code

County
Black or African Am. — Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on.
➜

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

Asian — Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on.

American Indian or Alaska Native — Print name of enrolled or principal
tribe(s), for example, Navajo Nation, Blackfeet Tribe, Muscogee (Creek)
Nation, Mayan, Doyon, Native Village of Barrow Inupiat Traditional
Government, and so on.

8.

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 7
Both places equally

Middle Eastern or North African — Print origin(s), for example, Lebanese,
Iranian, Egyptian, Syrian, Moroccan, Algerian, and so on.

Some other place

9.

On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire

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

The address or location you listed in Question 7
Some other place

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

➜

➜ If more people were counted in Question 2, on the front page,
continue with person 10

Continue to Question 6.

10

Use this section to complete information for the rest of the people you counted in Question 2 on the front page. We may call
for additional information about them.

Person 10
First Name

MI

Age on April 1, 2015

Sex

Date of Birth
Month
Day

Last Name

Related to Person 1?
Year of Birth

Male

Yes

Female

No

Person 11
First Name

MI

Age on April 1, 2015

Sex

Date of Birth
Month
Day

Last Name

Related to Person 1?
Year of Birth

Male

Yes

Female

No

Person 12
First Name

MI

Age on April 1, 2015

Sex

Date of Birth
Month
Day

Last Name

Related to Person 1?
Year of Birth

Male

Yes

Female

No

Person 13
First Name

MI

Age on April 1, 2015

Sex

Date of Birth
Month
Day

Last Name

Related to Person 1?
Year of Birth

Male

Yes

Female

No

Person 14
First Name

MI

Age on April 1, 2015

Sex

Date of Birth
Month
Day

Last Name

Related to Person 1?
Year of Birth

Male

Yes

Female

No

FOR OFFICIAL USE ONLY

Thank you for completing the
2015 National Census Test
11

JIC1

JIC2

Please mail your completed form to:
US CENSUS BUREAU
NATIONAL PROCESSING CENTER
1201 EAST 10TH STREET
JEFFERSONVILLE, IN 47132

If you need help completing this form, call 1–866–226–2836, Monday through Saturday from 9:00 a.m. to
9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
TDD — Telephone display device for the hearing impaired. Call 1–800–786–9448, Monday through Saturday
from 9:00 a.m. to 9:00 p.m. EST, and Sunday from 11:00 a.m. to 9:00 p.m. EST. The telephone call is free.
¿NECESITA AYUDA? Si usted necesita ayuda para completar este cuestionario, llame al 1–888–262-5931 de
lunes a sábado entre las 9:00 a.m. y las 9:00 p.m. EST, y los domingos entre las
11:00 a.m. y 9:00 p.m. EST. La llamada telefónica es gratis.

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

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