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pdfOMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
2015 Census Test
Use a blue or black pen.
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
Or go to https://survey.census.gov/censustest to complete the 2015 Census Test.
Start here
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.
The Census Bureau also conducts counts in institutions and other places, so:
• 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, 2015.
• 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:
• If someone who has no permanent place to stay is staying here on April 1, 2015, count that person.
1.
How many people were living or staying in this house, apartment, or mobile home on April 1, 2015?
Number of people =
2.
Were there any additional people staying here April 1, 2015 that you did not include in Question 1?
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 babysitters
People staying here temporarily
3.
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.
11125010
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
4.
What is your telephone number? We may call if we don’t understand an answer.
Area Code + Number
–
FORM
DD-1 (12-10-2014) Draft 7
–
§,-S+¤
No additional people
Person 1
5.
9.
No ➔ SKIP to Person 2, if more people live here.
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.
Yes — Mark ✗ all that apply.
In college housing
At a seasonal or second residence
In the military
In jail or prison
What is Person 1’s name? Print name below.
For a job or business
In a nursing home
First Name
For child custody
For another reason
MI
10.
Last Name
6.
If you marked yes to Question 9, please provide the full
address of the other place where Person 1 sometimes
lives or stays:
Address Number (For example: 5007)
What is Person 1’s sex? Mark ✗ ONE box.
Male
7.
Does Person 1 sometimes live or stay somewhere else?
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.
Age on April 1, 2015
Print numbers in boxes.
Month
Day
Apt/Unit (For example: "Apt. A" or "Lot 3")
Year of birth
Rural Route Address
8.
What is Person 1’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
State
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
County
➜ NOTE: If there is no street address or if this is a facility, please
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
print a description in the boxes below.
C
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. C
11.
Where does Person 1 live or stay most of the time?
The address printed on the back of this questionnaire
The address or location you listed in Question 10
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Both places equally
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
Some other place
12.
On April 1, 2015, where was Person 1 staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 10
Some other place
➜ If more people were counted in Question 1, continue with
Person 2.
➜ Continue to Question 9.
2
11125028
§,-S=¤
Vietnamese, Korean, Japanese, and so on.
ZIP Code
1.
Person 2
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 3.
➜ Continue to Question 6.
3
§,-SE¤
11125036
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C
1.
Person 3
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 4.
➜ Continue to Question 6.
4
11125044
§,-SM¤
Vietnamese, Korean, Japanese, and so on.
1.
Person 4
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 5.
➜ Continue to Question 6.
5
§,-ST¤
11125051
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C
1.
Person 5
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 6.
➜ Continue to Question 6.
6
11125069
§,-Sf¤
Vietnamese, Korean, Japanese, and so on.
1.
Person 6
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 7.
➜ Continue to Question 6.
7
§,-Sn¤
11125077
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C
1.
Person 7
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 8.
➜ Continue to Question 6.
8
11125085
§,-Sv¤
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C
1.
Person 8
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
C
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 9.
➜ Continue to Question 6.
9
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Vietnamese, Korean, Japanese, and so on.
1.
Person 9
Print name of
6.
First Name
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
Housemate or roommate
Stepson or stepdaughter
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:
Street Name (For example: N Maple Ave)
Foster child
Brother or sister
Other nonrelative
Father or mother
What is this person’s sex? Mark ✗ ONE box.
Male
Apt/Unit (For example: "Apt. A" or "Lot 3")
Female
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 April 1, 2015
5.
In jail or prison
Roomer or boarder
Adopted son or daughter
4.
At a seasonal or second residence
In the military
Address Number (For example: 5007)
Other relative
Biological son or daughter
3.
7.
In college housing
Month
Day
Rural Route Address
Year of birth
What is this person’s race or origin? Mark ✗ ONE or
more boxes AND write in the specific race(s) or origin(s).
White – Print origin(s), for example, German, Irish, English, Italian,
Lebanese, Egyptian, and so on. C
City
State
Hispanic, Latino, or Spanish origin – Print origin(s), for example,
Mexican or Mexican American, Puerto Rican, Cuban, Dominican,
Salvadoran, Colombian, and so on. C
ZIP Code
County
Black or African Am. – Print origin(s), for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Ghanaian, and so on. C
➜ NOTE: If there is no street address or if this is a facility, please
print a description in the boxes below.
8.
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. C
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
Native Hawaiian or Other Pacific Islander – Print origin(s), for
Some other place
example, Native Hawaiian, Samoan, Guamanian or Chamorro, Tongan,
Fijian, Marshallese, and so on. C
9.
On April 1, 2015, where was this person staying?
The address printed on the back of this questionnaire
Some other race or origin – Print race(s) or origin(s). C
The address or location you listed in Question 7
Some other place
➜ If more people were counted in Question 1, on the front
page, continue with Person 10.
➜ Continue to Question 6.
10
11125101
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Asian – Print origin(s), for example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, and so on. C
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.
Person 10
First Name
MI
Last Name
Date of Birth
Sex
Age on April 1, 2015
Male
Month
Day
Year of birth
Female
Related to Person 1?
Yes
No
Person 11
First Name
MI
Last Name
Date of Birth
Sex
Age on April 1, 2015
Male
Month
Day
Year of birth
Female
Related to Person 1?
Yes
No
Person 12
First Name
MI
Last Name
Date of Birth
Sex
Age on April 1, 2015
Male
Month
Day
Year of birth
Female
Related to Person 1?
Yes
No
Person 13
First Name
MI
Last Name
Date of Birth
Age on April 1, 2015
Male
Month
Day
Year of birth
Female
Related to Person 1?
Yes
No
Person 14
11125119
First Name
MI
Last Name
Date of Birth
Sex
Age on April 1, 2015
Male
Month
Day
Year of birth
Female
Related to Person 1?
Yes
No
FOR OFFICIAL USE ONLY
Thank you for completing the
2015 Census Test.
11
JIC1
JIC2
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Sex
If your enclosed postage-paid envelope is missing, please mail your completed form to:
U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132
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. and Sunday from 11:00 a.m. to 9:00 p.m. 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. y los domingos entre las 11:00 a.m. y 9:00 p.m.
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, DMD-3H174, 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.
12
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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. and Sunday from 11:00 a.m. to 9:00 p.m. The telephone call is free.
| File Type | application/pdf |
| File Modified | 2015-02-11 |
| File Created | 2014-11-25 |