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pdfAttachment C
OMB No. 0607-0368
COVERAGE
C1.
FORM SC-1(Phone/WYC) U.S. DEPARTMENT OF COMMERCE
(02-10-2012) Draft 2
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?
AA
Barcode ID
PHONE/WYC
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.
House Number
Street Name
Special Census
No – Continue with C2.
C2.
SC ID
Yes – Delete person(s) from question 1 by marking the "Cancel" box. Correct the POP count in question S5 on the front cover.
Zip Code
Apartment Number/Unit Designation
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?
Continuation form(s) attached
Write either Rural Route or Location Description in the box below.
Number of continuation forms
for this address
No – Continue with H1.
INSTRUCTIONS
HOUSING
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?
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?
H2.
Single Family Structure
RESPONDENT INFORMATION
R1.
Enter respondent’s name.
Occupy without
payment of rent
Mobile Home
Boat/Tent/Other
RECORD OF CONTACT
Multi-Unit Structure
R2.
Rent
In case we need to contact you, what is
your telephone number, address, and the
best time to call?
R3.
Type:
R4.
Respondent —
First Name
Lived here on
Special Census
Date
Are there any other
living quarters either
occupied or vacant
at this address?
Month
Day
Month
Time
/
Phone
/
Phone
Outcome
:
:
a.m.
a.m.
p.m.
Moved in after
Special Census
Date
Last Name
Is neighbor or
other proxy
INTERVIEW SUMMARY
A.
Unit Status on Special Census Date
B.
POP on Special
Census Date
C.
D.
E.
PI
Not transcribed (original
questionnaire still in field). .
§!++/¤
=
=
=
=
=
=
=
=
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 below C
RE = Refusal
CI = Conducted interview
OT = Other
a.m.
p.m.
TR = Transcribed information
to labelled SC-1
NT = No transcription
/
Not transcribed (PHONE/
WYC response matches
original questionnaire) . . . .
/
Not transcribed (PHONE/
WYC response outside SC
area . . . . . . . . . . . . . . . . . .
/
INTRODUCTION
S1.
F.
1
2
3
4
5
6
7
8
:
/
REP
For rent
01–49 = Total persons
00 = Vacant
98 = Delete
99 = POP unknown
Phone
OUTCOME CODES:
No
If vacant, ask: Which category best
describes this vacant unit as of
(Special Census Date)? (Read categories.)
/
Transcribed (PHONE/WYC
response altered original
Pop count). . . . . . . . . . . . . .
/
p.m.
Yes (List unit on
SC-921 Add page
if it is not listed
on the SC-920
Listing Sheet)
Transcribed (PHONE/WYC
HU added to SC) . . . . . . . . .
Day
CO
G.
REF
Rented, not occupied
Yes – Respondent indicates they want to fill out their questionnaire over the phone – Continue with S2.
S2.
For sale only
H.
Thank you for calling the Census Bureau. My name is . . . May I help your?
TU
Completing a questionnaire for your household takes about 10 minutes. A Privacy Act Notice was left at your door by an
enumerator (WYC version: The Privacy Act Notice was printed in the newspaper) and explains that your answers are confidential.
Did you receive (or read) this notice? (If the respondent answers "no" or is not clear on what you are describing, read the Privacy Act Notice
to them over the phone.)
What is your exact address? (fill label area above, including location description if necessary)
Sold, not occupied
Did you or anyone in your household live at this address on (Special Census date)?
For seasonal, recreational,
or occasional use
I.
For migrant workers
S3.
S4.
CERTIFICATION
Enumerator’s signature
Does someone usually live at this (house/apartment/mobile home), or is this a vacation or seasonal home?
Usually lives here – Skip to question S5.
Other vacant
I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.
No – Skip to question S4.
Yes – Continue with question S3.
J. JIC2
JIC1
Crew Leader’s
initials
Vacation or seasonal home or held for occasional use –
Skip to question H2 on the back page.
(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.
CLD number
S5.
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.
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)?
Month
Day
Year
Employee ID Code
Month
Day
Year
Number of people
00101014
H1.
1. Use this form to record answers to telephone interviews received in the office or through the Were You Counted campaign.
2. Complete all sections according to usual procedures associated with emumerator-filled questionnaires.
3. Transcribe all information from this form to a regular SC-1 questionnaire that has address information and barcode. This form
(SC-1 Phone/WYC) cannot be sent to NPC for processing.
4. After transcribing the contents of this form to a barcoded SC-1, destroy this form according to proper disposal procedures
associated with Title 13 data.
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
Add
FORM SC-1(Phone/WYC) (02-10-2012) Draft 2
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.
| File Type | application/pdf |
| File Title | sc1_phone_wyc_p1.g |
| File Modified | 2012-05-30 |
| File Created | 2012-02-10 |