SC-1 Special Census Enumerator Questionnaire

Attachment A

OMB No. XXXX-XXXX

COVERAGE

C1.

FORM SC-1
(04-09-2012) Draft 21

U.S. DEPARTMENT OF COMMERCE

SC ID

State

County

Tract

Economics and Statistics Administration

U.S. CENSUS BUREAU

I need to make sure I have counted everyone who lived or stayed here on (Special Census Date). Did I miss —
– any children, including babies or foster children?
– any other relatives?
– any roommates?
– any other nonrelatives?
– anyone else staying here on (Special Census Date) who had no permanent place to live?

ENUMERATOR
QUESTIONNAIRE

Yes – Add person(s) to question 1, mark the "Add" box, and ask questions 2—6. Correct the POP count in question S5 on the front cover.

Block

AA

Map Spot

Barcode ID

Special Census

No – Continue with C2.
On (Special Census Date), were any of the people you told me about living or staying somewhere else for any of these reasons:
– in college housing?
– in the military?
– in jail or prison?
– in a nursing home?
Yes – Delete person(s) from question 1 by marking the "Cancel" box. Correct the POP count in question S5 on the front cover.

Is this an added unit or is
there a change to the
preprinted address label?

HOUSING

H2.

Do you or does someone in this household own this (house/apartment/mobile home) with a mortgage or loan, including
home equity loans; own it free and clear; rent it; or occupy it without having to pay rent?

Yes – Enter the full
address in the address
change section ➔

Own free and
Own with a mortgage
clear (without a
or loan (including
mortgage or loan)
home equity loans)
What type of structure is this unit?

No – Skip to S1

Single Family Structure

RESPONDENT INFORMATION

R1.

Rent

Multi-Unit Structure

R2.

Enter respondent’s name.

Occupy without
payment of rent

Mobile Home

In case we need to contact you, what is
your telephone number, address, and the
best time to call?

Mark box with a Letter:
R (Rural Route)
L (Location Description)

Boat/Tent/Other

R3.

R4.

Respondent —

First Name

Lived here on
Special Census
Date

Are there any other
living quarters either
occupied or vacant
at this address?
Yes (List unit on
SC-921(HU) Add
page, if it is not
listed on the
SC-920(HU)
Listing Sheet, and
complete a blank
SC-1)

Moved in after
Special Census
Date

Last Name

Is neighbor or
other proxy

INTERVIEW SUMMARY

A.

Number of continuation forms
for this address

ADDED UNIT ADDRESS or ADDRESS CHANGES

No – Continue with H1.

H1.

Unit Status on Special Census Date

B.

POP on Special
Census Date

C.

No

D.

If vacant, ask: Which category best
describes this vacant unit as of
(Special Census Date)? (Read categories.)

E.

PI

REP

House Number

(R or L)

RECORD OF CONTACT
OUTCOME CODES:

§!++/¤

1
2
3
4
5
6
7
8

=
=
=
=
=
=
=
=

Occupied
Vacant – regular
Vacant – usual home elsewhere
Demolished
Burned out/cannot locate/outside block
Nonresidential
Empty mobile home/trailer site
Uninhabitable (open to elements,
condemned, under construction)
9 = Duplicate of Barcode ID belowC

01–49 = Total persons
00 = Vacant
98 = Delete
99 = POP unknown

CO

G.

REF

Rented, not occupied

✗

Personal

Time

Outcome

/

:

a.m.

p.m.

Telephone

/

:

a.m.

p.m.

Personal

Telephone

/

:

a.m.

p.m.

CI = Conducted
Interview

Personal

Telephone

/

:

a.m.

p.m.

OT = Other

Personal

Telephone

/

:

a.m.

p.m.

Personal

Telephone

/

:

a.m.

p.m.

RE = Refusal

INTRODUCTION

For sale only
TU

S4.

Hello, I’m (Name) from the U.S. Census Bureau.
(Show ID). Is this (Address)?

(Only ask if no household member lived here on Special Census
Date.) On (Special Census Date), was this unit vacant, or
occupied by a different household?
Vacant – Skip to question H2 on the back page.

Yes – Continue with question S2

Sold, not occupied
For seasonal, recreational,
or occasional use

I.

J. JIC2

JIC1

S2.

For migrant workers

No – Ask: Can you tell me where to find (Address)?
END INTERVIEW.
I’m here to complete a Special Census questionnaire for this
address. It should take about 10 minutes. (Hand respondent
an Information Sheet.) The first part explains that your
answers are confidential. I’ll refer to the other parts later.
Did you or anyone in this household live or stay here on
(Special Census Date)?
Yes – Continue with question S3.

I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.
Enumerator’s signature

Year

Day

Personal

CERTIFICATION

Day

Month

NC = No Contact

Other vacant

Month

Zip Code

Write either Rural Route or Location Description in the box below.

Type:

NV = Left Notice
of Visit

S1.
H.

Street Name

Apartment Number/Unit Designation

For rent

F.

APPLY PREPRINTED LABEL HERE

Continuation form(s) attached

Employee ID Code

No – Skip to question S4.

Crew Leader’s
initials

CLD number

Month

Year

Day

S3.

Does someone usually live at this
(house/apartment/mobile home), or is this a vacation
or seasonal home?

Occupied by a different household – Using a knowledgeable
respondent, complete this questionnaire for the Census Date
household.
Not a housing unit – Skip to "Respondent Information" on
back page.

S5.

We need to count people where they live and sleep most
of the time.
Please look at list A. It contains examples of people who
should and should not be counted at this place.
Based on these examples, how many people were living
or staying in this (house/apartment/mobile home) on
(Special Census Date)?

Usually lives here – Skip to question S5.
Vacation or seasonal home or held for occasional use –
Skip to question H2 on the back page.

Number of people

00101014

C2.

Let’s make a list of all those people. Please
start with the name of an owner or renter
who was living here on (Special Census Date).
Otherwise, start with any adult living here.

Person 1

2.

Please look at list B on the Information Sheet.
How is (Name) related to (Read name of Person 1)?
Mark ✗ ONE box.

✗

First Name

3.

Is (Name) male or
female?
Mark ✗ ONE box.

Male

Person 1

4. What was (Name’s) age on (Special Census
Date)? What is (Name’s) date of birth?

Please report babies as age 0 when the child
is less than 1 year old. Print numbers in boxes.

Female

Age on
Special Census Date

MI

DATE OF BIRTH

5. Please look at List C. Is (Name) of Hispanic, 6. Please look at List D and choose one or more races. For this Special Census, Hispanic origin
Latino, or Spanish origin?

Read if necessary: Examples of another Hispanic, Latino, or
Spanish origin include Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.

White

Black or
African
American

American
Indian or
Alaska
Native

Yes, Puerto Rican

Asian
Indian

Chinese

Filipino

Yes, Cuban

Japanese

Korean

Vietnamese

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

Native
Hawaiian

Guamanian
or Chamorro

Samoan

No, not of Hispanic, Latino, or
Spanish origin
Yes, Mexican, Mexican American,
Chicano

Last Name

Month

Day
Cancel

Add

First Name

MI

Last Name

Cancel

Add

Person 3
First Name

MI

Last Name

Cancel

Add

Person 4
First Name

MI

Husband
or wife

Grandchild

Unmarried
partner

Biological son
or daughter

Parent-in-law

Other
nonrelative

§!++7¤

Last Name

Add

Person 5
First Name

MI

Last Name

Cancel

FORM SC-1 (04-09-2012) Draft 21

Add

Male

Female

Age on
Special Census Date
DATE OF BIRTH

Adopted son
or daughter

Son-in-law or
daughter-in-law

Stepson or
stepdaughter

Other relative

Brother or
sister

Roomer or boarder

Father or
mother

Housemate or roommate

Husband
or wife

Grandchild

Unmarried
partner

Biological son
or daughter

Parent-in-law

Other
nonrelative

Adopted son
or daughter

Son-in-law or
daughter-in-law

Stepson or
stepdaughter

Other relative

Brother or
sister

Roomer or boarder

Father or
mother

Housemate or roommate

Husband
or wife

Grandchild

Unmarried
partner

Parent-in-law

Other
nonrelative

Biological son
or daughter

Cancel

Some other race — What is that group?

Year of birth

Person 2

Month

Day

Female

Age on
Special Census Date
DATE OF BIRTH
Month

Day

Female

Age on
Special Census Date
DATE OF BIRTH

Adopted son
or daughter

Son-in-law or
daughter-in-law

Stepson or
stepdaughter

Other relative

Brother or
sister

Roomer or boarder

Father or
mother

Housemate or roommate

Husband
or wife

Grandchild

Biological son
or daughter

Parent-in-law

Month

Day

Asian
Indian

Chinese

Filipino

Yes, Cuban

Japanese

Korean

Vietnamese

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Other
nonrelative

Adopted son
or daughter

Son-in-law or
daughter-in-law

Stepson or
stepdaughter

Other relative

Brother or
sister

Roomer or boarder

Father or
mother

Housemate or roommate

Male

Female

Age on
Special Census Date
DATE OF BIRTH
Month

Day

Year of birth

Other Asian —

➤

American
Indian or
Alaska
Native

Yes, Puerto Rican

Asian
Indian

Chinese

Filipino

Yes, Cuban

Japanese

Korean

Vietnamese

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Some other race — What is that group?

Other Asian —

➤

American
Indian or
Alaska
Native

Yes, Puerto Rican

Asian
Indian

Chinese

Filipino

Yes, Cuban

Japanese

Korean

Vietnamese

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Some other race — What is that group?

Other Asian —

➤

American
Indian or
Alaska
Native

Yes, Puerto Rican

Asian
Indian

Chinese

Filipino

Yes, Cuban

Japanese

Korean

Vietnamese

Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C

Native
Hawaiian

Guamanian
or Chamorro

Samoan

Some other race — What is that group?

What is that

Other Pacific
Islander — What is that group?

Black or
African
American

Yes, Mexican, Mexican American,
Chicano

What is the name of the enrolled or
principal tribe? C

group? C

White

No, not of Hispanic, Latino, or
Spanish origin

What is that

Other Pacific
Islander — What is that group?

Black or
African
American

Yes, Mexican, Mexican American,
Chicano

What is the name of the enrolled or
principal tribe? C

group? C

White

No, not of Hispanic, Latino, or
Spanish origin

What is that

Other Pacific
Islander — What is that group?

Black or
African
American

Yes, Mexican, Mexican American,
Chicano

What is the name of the enrolled or
principal tribe? C

group? C

White

No, not of Hispanic, Latino, or
Spanish origin

Year of birth
Unmarried
partner

➤

Yes, Puerto Rican

Some other race — What is that group?

What is that

Other Pacific
Islander — What is that group?

American
Indian or
Alaska
Native

Year of birth
Male

Other Asian —

Black or
African
American

Yes, Mexican, Mexican American,
Chicano

What is the name of the enrolled or
principal tribe? C

group? C

White

No, not of Hispanic, Latino, or
Spanish origin

Year of birth
Male

is not a race. What is (Name’s) race?
Read if necessary: Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. Examples of other Pacific Islander groups include Fijian, Tongan, and so on.

What is the name of the enrolled or
principal tribe? C

Other Asian —

What is that

group? C

Other Pacific
Islander — What is that group?
➤

00101022

1.