DY-1W TE3 2017 Census Test Experimental Form 3

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Start here

R
AF

T

2017 Census Test

OR go to https://survey.census.gov/censustest to complete the 2017 Census Test.

Use a blue or black pen.

2.

Before you answer Question 1, count the people living in this
house, apartment, or mobile home using our guidelines.
• Count all people, including babies, who live and sleep here
most of the time.
• If no one lives or sleeps at this address, go to
https://survey.census.gov/censustest or call the number
on page 8.
The Census Bureau also conducts counts in institutions and
other places, so:

Children, such as newborn babies or foster children
Relatives, such as adult children, cousins, or in-laws

D

Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
No additional people

3.

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)?

• Leave these people off your form, even if they will return to
live here after they leave college, the nursing home, the
military, jail, etc. Otherwise, they may be counted twice.
The Census must also include people without a permanent
place to stay, so:

Rented?
Occupied without payment of rent?

4.

• If someone who has no permanent place to stay is staying
here on April 1, 2016, count that person.

1.

Is this house, apartment, or mobile home — Mark ✗ ONE box.

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

How many people were living or staying in this house,

–

apartment, or mobile home on April 1, 2016?
Number of people =
FORM

DY-1W-TE3

–

§,CS/¤

11345014

• Do not count anyone living away either at college or in the
Armed Forces.
• Do not count anyone in a nursing home, jail, prison, detention
facility, etc., on April 1, 2016.

Were there any additional people staying here April 1, 2016
that you did not include in Question 1?
Mark ✗ all that apply.

8.

Person 1
5. Please provide information for each person living here. If

WHITE – Provide details below.

there is someone living here who pays the rent or owns this
residence, start by listing him or her as Person 1. If the
owner or the person who pays the rent does not live here,
start by listing any adult living here as Person 1.

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

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

What is Person 1's race or ethnicity?
Mark all boxes that apply AND print details in the spaces below.
Note, you may report more than one group.

MI
HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
or Mexican
American
Salvadoran

Last Name(s)

Puerto
Rican

Cuban

Dominican

Colombian

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

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

7.

BLACK OR AFRICAN AMERICAN – Provide details below.

Female

African
American
Nigerian

years

Print numbers in boxes.
Month
Day

Haitian

Ethiopian

Somali

Print, for example, Ghanaian, South African, Barbadian, etc.

What is Person 1’s age and what is Person 1’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on April 1, 2016

Jamaican

T

Male

R
AF

6.

ASIAN – Provide details below.

Year of birth

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Provide details below.
American
Indian

Alaska
Native

Central or South
American Indian

D

Print, for example, Navajo Nation, Blackfeet Tribe, Mayan,
Aztec, Native Village of Barrow Inupiat, Tlingit, etc.

§,CS7¤

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Algerian

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print below.

2

11345022

Print, for example, Israeli, Iraqi, Tunisian, etc.

Person 1
9a. On April 1, 2016, was Person 1 enrolled in any
American Indian tribe or Alaska Native tribe or village?

12.

☐No, not enrolled -> Skip to question 10
☐Yes, enrolled

If you marked yes to Question 11, please provide the
full address of the other place where Person 1
sometimes lives or stays.
Address Number (For example: 5007)

9b. What is the name of the American Indian tribe or Alaska
Native tribe or village Person 1 was enrolled in on April 1st?
Print enrolled tribe(s) or village(s) below.

Street Name (For example: N Maple Ave)

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

10. On April 1, 2016, was Person 1 a shareholder of an

Alaska Native Claims Settlement Act (ANCSA) Corporation?

AF

Print Alaska Native Corporation(s) below.

T

Rural Route Address (if there is no street address)

☐No, not a shareholder
☐Yes, a shareholder

City

R

State

ZIP Code

County, Parish, or Borough

11.Does Person 1 sometimes live or stay somewhere else?
No ➔ SKIP to the next page if more people live here.

➜ NOTE: Please provide a location description below if there is no
address or if this is a facility.

D

Yes, for college

Yes, with a parent or
other relative

Yes, for a military assignment

Yes, at a seasonal or
second residence

Yes, for a job or business

Yes, in jail or prison

Yes, in a nursing home

Yes, for another reason

13.

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

Both places equally
Some other place

11345030

14.

On April 1, 2016, where was Person 1 staying?
The address printed on the front of this questionnaire
The address or location you listed in Question 12
Some other place

3

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The address or location you listed in Question 12