SC-921(TU) Transitory Unit Add Page

Attachment L
OMB No. 0607-0368: Approval Expires XX/XX/XXXX
FORM SC-921(TU)
(6-7-2012)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

IDENTIFICATION

Page

of

U.S. CENSUS BUREAU

TRANSITORY UNIT ADD PAGE
Special Census
This form contains confidential information, including Title 13 and
Personally identifiable information (PII), the release of which is protected
by the Privacy Act of 1974.
Employee ID No.

NOTICE
Employee name

a. SCID

Name

b. State

c. County

e. AA Number
g. TL
1. Name

d. Tract
f. Barcode
ID

2. Address
INSTRUCTIONS: Print the space or unit number (occupied or unoccupied) – except for
hotels or motels where you will only write in the unit numbers provided by the contact person).
Be sure to list spaces or units as they appear on ground. Identify which spaces have mobile
home (with or without wheels) on them by marking the box with an "X" in the MH in Column (1).
• Print space or unit number in column (1). Mark (X) if space is occupied in column (2).
Is this space
occupied?
Mark (X) one
(2)

Print the space or
unit number
(1)

MH

MH

MH

MH

MH

MH

Yes

Yes

Yes

Yes

Yes

Yes

Does everyone here have another place to
live besides this (RV/boat/room/unit)?
(3)

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

No – END

Yes – Go to column (4)
No – Complete SC-1
Refused

NC1 – No Contact 1 st visit
NC2 – No Contact 2 nd visit

• Approach the space and use the following script:
Hello, I’m (your name) from the U.S. Census Bureau. (Show ID card.)
To make sure we count everyone who would be residents in the Special
Census, we visit places like hotels, motels, RV parks, and marinas.
• Hand the respondent an SC-1(F), Information Sheet, and allow time so they can read the
Confidentiality Notice. Continue with column (3).
Does anyone spend more
time in this (RV/boat/room/unit)
than at another place?
(4)
Yes, more time in this unit –
Complete SC-1
No – Go to column (5)
Yes, more time in this unit –
Complete SC-1

Name of Respondent
(Last Name, First Name)

Processing ID Label

(5)

(6)
Place Processing ID
Label Here

Place Processing ID
Label Here

No – Go to column (5)
Yes, more time in this unit –
Complete SC-1
No – Go to column (5)
Yes, more time in this unit –
Complete SC-1
No – Go to column (5)
Yes, more time in this unit –
Complete SC-1
No – Go to column (5)
Yes, more time in this unit –
Complete SC-1
No – Go to column (5)

Place Processing ID
Label Here

Place Processing ID
Label Here

Place Processing ID
Label Here

Place Processing ID
Label Here

MH – Mobile Homes
Mobile homes (also called trailers) are usually placed in one location and not expected to be moved,
but may retain the ability to be moved. They may have a covering around the foundation or they may

DRAFT #5 (06/07/2012)

be elevated off the ground. A recreational vehicle (RV) or camping trailer is expected to be moved
under its own power or towed.