Download:
pdf |
pdfAttachment B
OMB No. XXXX-XXXX
NOTES
FORM SC-1(SUPP) U.S. DEPARTMENT OF COMMERCE
(11-29-2011) Draft 8
Economics and Statistics Administration
U.S. CENSUS BUREAU
SC ID
AA
Barcode ID (Transcribe Barcode ID from the label on SC-1 Questionnaire)
ENUMERATOR
CONTINUATION
QUESTIONNAIRE
Special Census
Form
of
form(s)
ADDRESS
House Number / Street Name
Apartment Number / Unit Designation
ENUMERATOR CONTINUATION
00111013
§!,+.¤
QUESTIONNAIRE
2.
Who else lived or stayed here on
(Special Census Date)?
Please look at list B on the Information Sheet.
How is (Name) related to (Read name of Person 1)?
Mark ✗ ONE box.
Person No.
First Name
MI
Last Name
Cancel
Add
Person No.
First Name
MI
Last Name
Cancel
Add
Person No.
First Name
MI
Last Name
Cancel
Add
Person No.
First Name
MI
§!,+6¤
Last Name
Cancel
Add
Person No.
First Name
MI
Last Name
Cancel
FORM SC-1(SUPP) (11-29-2011) Draft 8
Add
Is (Name) male or
female?
Mark ✗ ONE box.
Husband
or wife
Grandchild
Unmarried
partner
Biological son
or daughter
Parent-in-law
Other
nonrelative
Male
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
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
Month
Day
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.
Male
Female
Age on
Special Census Date
DATE OF BIRTH
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
Month
Day
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
Yes, Mexican, Mexican American,
Chicano
Some other race — What is that group?
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.
White
No, not of Hispanic, Latino, or
Spanish origin
Year of birth
Adopted son
or daughter
Biological son
or daughter
3.
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?
➤
00111021
1.
| File Type | application/pdf |
| File Title | sc1(supp)_p1.g |
| File Modified | 2012-05-30 |
| File Created | 2011-11-29 |