SC-351 GQ Initail Contact Checklist

FORM

SC-351

Attachment H

(6-8-2012)

SCID

Block

U.S. DEPARTMENT OF COMMERCE

State

County

Tract

AA

Map Spot

GQ Type

Unit ID

Economics and Statistics Administration

U.S. CENSUS BUREAU

GQ INITIAL CONTACT
CHECKLIST
Special Census

NOTICE

This form contains confidential information,
including Title 13 and Personally Identificable
Information (PII), the release of which is
protected by the Privacy Act of 1974.

Section 1 – INTRODUCTION
Hello. My name is (Your name). I’m from the U.S. Census Bureau. We are conducting a
special census in this area to update the housing and population count. I’d like to
speak with someone who can verify the information we have about your facility and to
set up an appointment for Census Bureau employees to enumerate the residents or
clients at your facility.
We estimate that it will take approximately 10 minutes to collect this information. This
census has been approved by the Office of Management and Budget under OMB No.
0607-0368. Your answers are confidential and protected by law. All U.S. Census Bureau
employees have taken an oath and are subject to a jail term, a fine, or both if they
disclose ANY information that could identify you, your facility, or its residents.

Section 2 – FACILITY NAME AND ADDRESS
NAME OF FACILITY

2.1 We have your facility listed as
Is this name correct?
1
2

Yes – Go to Q2.2
No – Enter correct name
FACILITY ADDRESS

2.2 We have your address listed as
Is this address correct?
1
2

Yes – Go to Q2.3
No – Enter correct address

2.3 If the facility address does not include a house number/street name – ASK:
Please describe where your facility is located—for example, the intersection of two
streets, or the approximate distance from intersecting road(s).

Continue with Section 3

Section 3 – CONTACT INFORMATION
3.1 May I have your full name please, including your middle initial?

3.2 Do you have a job title that we can note for our records?

AREA CODE AND TELEPHONE NUMBER

3.3 I called you at
1
2

. Is this the best number to reach you?

Yes – Go to Interviewer Instructions
No – Enter area code, telephone number, and extension if applicable.
AREA CODE

TELEPHONE NUMBER

EXTENSION

Go to the Interviewer Instructions section.

INTERVIEWER
INSTRUCTIONS

For added GQs – Ask Q.4.1, then go to Q.4.2
If not a GQ add – Go to Q.4.2

Section 4 – TYPE OF FACILITY
4.1 What is the name of this facility?

4.2 Because the list is long – Go to the section that best fits the category of the facility. Read the bolded
titles first until respondent indicates which category best describes this facility then read the rest of the
paragraph for that category.
I am going to read a list of facilities where people live or stay. Please tell me which
category BEST describes your facility.
Is this facility primarily a –
CORRECTIONAL FACILITY
Correctional facility intended for adults?
This includes: A federal detention center such as a Metropolitan detention center, Metropolitan
Correctional Center, Bureau of Indian Affairs detention center, Immigration and Customs
Enforcement Service Processing Centers, and contract detention facilities . . . . . . . . . . . . . . . . . . . . 101
Federal prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Local county jail or a correctional facility operated by the American Indian and Alaska
Native (AIAN) tribal governments (also included are work farms and camps holding people
awaiting trial or serving short sentences) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Correctional residential facility (including a halfway house, restitution center, prerelease
center and work release center) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 102
. . . . . 103

. . . . . 104
. . . . . 105

Correctional institution intended for adults 18 and over but may also include
juveniles? This group also includes halfway houses operated for correctional purposes . . . . . . . . 105

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FORM SC-351 (6-8-2012)

Section 4 – TYPE OF FACILITY – Continued
Correctional facilities intended for juveniles?
This includes specialized facilities that provide strict confinement for its residents and detain
juveniles awaiting adjudication, commitment or placement, or those being held for diagnosis or
classification. Also included are correctional facilities where residents are permitted contact with
the community, for purposes such as attending school or holding a job. . . . . . . . . . . . . . . . . . . . . . 203
GROUP HOMES
Group Homes for Juveniles?
Group living arrangements in residential settings that are able to accommodate three or more
clients of a service provider that provides room and board and services, including behavioral,
psychological, or social programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Group Homes for Adults?
Community-based group living arrangements in residential settings that are able to accommodate
three or more clients of a service provider. The group home provides room and board and
services, including behavioral, psychological, or social programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
MILITARY
Military Quarters – These facilities include military personnel living in barracks (including "open"
barrack transient quarters) and dormitories and military ships.
Military barrack or dormitory, non-disciplinary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Military ships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
Military disciplinary barracks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Military hospital for active duty personnel assigned to a bed? . . . . . . . . . . . . . . . . . . . 404
Military hospital or ward for the chronically ill? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
HEALTH CARE FACILITY
Skilled nursing facility, nursing facility or independent or assisted living facility?
Mark (X) both choices if facility has both assisted living and nursing care – Includes facilities licensed
to provide medical care with seven day, twenty-four hour coverage for people requiring long-term
non-acute care. People in these facilities require nursing care, regardless of age. Either of these
facilities may be referred to as a nursing home.
Assisted living facility – Individual apartments with no nursing or medical care . . . . . . . . . . . . . . . HU
Give this information to your Supervisor.
Skilled nursing facility or nursing facility (nursing home) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Non-military hospital, hospice, or institution or school for people with mental
or physical impairment:
Mental (psychiatric) hospital and psychiatric units in other hospitals . . . . . . . . . . . . . . . . .
Hospital with patients who have no usual home elsewhere . . . . . . . . . . . . . . . . . . . . . . . .
In-patient hospice facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Residential schools for people with disabilities, including the physically
or developmentally disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 401
. . . . . 402
. . . . . 403
. . . . . 405

Residential Treatment Centers for Adults (non-correctional)?
Residential facilities that provide treatment on-site in a highly structured live-in environment for
the treatment of drug or alcohol abuse, mental illness, and emotional or behavioral disorders. . . . . . 802
Residential Treatment Centers for Juveniles (non-correctional)?
Includes facilities that primarily serve youth that provide services on-site in a highly structured
live-in environment for treatment of drug, alcohol abuse, mental illness and emotional or behavioral
disorders. These facilities are staffed 24 hours a day. These are not correctional facilities. . . . . . . . . 202
Continue with Section 4
FORM SC-351 (6-8-2012)

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Section 4 – TYPE OF FACILITY – Continued
STUDENT, CLERGY AND WORKER DORMS
Residence Hall, Dormitory, or Fraternity/Sorority House for College, University,
or Seminary Students?
Includes residence halls or dormitories which house college and university students in a group living
arrangement. These facilities are owned, leased, or managed either by a college, university, or
seminary, or by a private entity or organization. Fraternity and sorority housing recognized by the
college or university are included as college student housing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Workers’ Group Living Quarters and Job Corps Center?
Includes facilities such as dormitories, bunkhouses, and similar types of group living
arrangements for agriculture and non-agriculture workers. This category also includes facilities
that provide a full-time, year-round residential program offering a vocational training and
employment program that helps young people aged 16 to 24 to learn a trade, earn a high
school diploma or GED and get help finding a job. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901
Religious Group Quarters?
These are living quarters owned or operated by religious organizations that are intended to
house their members in a group living arrangement. This category includes convents,
monasteries, and abbeys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 902
LIVING QUARTERS FOR PEOPLE EXPERIENCING HOMELESSNESS
Shelters – Emergency shelter and Transitional shelters (with Sleeping Facilities)
for People Experiencing Homelessness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Domestic Violence Shelter?
Includes community-based homes, shelters or crisis centers that provide housing for people
who have sought shelter from household violence and may have been physically abused. . . . . . . . . 703
Targeted Nonsheltered Outdoor Locations?
Outdoor locations where people experiencing homelessness live without paying to stay . . . . . . . . . . 706
Living Quarters for Victims of Natural Disasters?
These are temporary group living arrangements established as a result of natural disasters . . . . . . . 903
Hotel/Motel/Hostel, Single Room Occupancy Units, Inn, Resort, Lodge, or
Bed & Breakfast:
Is this hotel used entirely to house people experiencing homelessness? If yes . . . . . . . . . . . . 701
Are there any rooms occupied by people who live or stay here most of the time (long-term
occupants)? If yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TL
Give this information to your Supervisor.
If "No" to both questions, then say "Thank you very much for your time.
This ends our interview," and end the interview.

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FORM SC-351 (6-8-2012)

Section 5 – METHOD OF ENUMERATION
Explain to the contact how the enumeration can be conducted.
If you have a roster or a listing of your clients we can enumerate through a
method called "Administrative Records" – In this type of enumeration we
would visit your facility and using your records, we would fill out a separate
Census questionnaire for each person that stayed at your facility on the
Special Census Date. These records need to give us information such as the
name, age and date of birth, sex, Hispanic origin, and race of your clients.
We will need a quiet space to work in, away from the general traffic at your
facility.
If you have a small facility – We can visit your facility at a set date and time
and interview each client separately. We will fill out a Census questionnaire
for each person in your facility including children.

5.1 Does your facility keep records that provide information on age, race, and/or sex of
your residents and/or clients?
1
Yes – Go to Q5.2
2
No – Go to Instruction Box below

5.2 Are these paper records, computer records, or both?
1
2
3

Paper
Computer
Both

5.3 If requested, could you make these records available to the Census Bureau?
1
2

Yes
No

5.4 What is the maximum number of persons your facility can accommodate?
Number of persons
Go to Instruction Box below

Go to the questions for the appropriate locations listed below:

INSTRUCTION
BOX

•
•
•
•

If a Shelter – Go to Q5.5
If a Hotel/Motel – Go to Q5.7
If a targeted nonsheltered outdoor location – Go to Q5.9
if an added GQ – Go to Q5.10

Ask for SHELTERS only.

5.5 Are your clients male only, female only, or both?
1
2
3

Male only
Female only
Both male and female

5.6 What is the maximum number of persons your facility can accommodate?
Number of persons
SKIP to Q5.11
FORM SC-351 (6-8-2012)

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Section 5 – METHOD OF ENUMERATION – Continued
5.7

Ask for HOTELS/MOTELS
Do you have units where staff or guests live permanently?
1
2

5.8

Yes
No

If "Yes" – What is the maximum number of persons your facility can accommodate?
Number of persons
SKIP to Q5.11

5.9

Ask for TARGETED NONSHELTERED OUTDOOR LOCATIONS only
Approximately, how many people will be here on (Special Census Date) from 12:00
midnight to 6:00 a.m.?
Number of persons
SKIP to Q5.11
Ask for ADDED GQs only

5.10 What is the maximum number of residents/clients/units your facility/location can
accommodate?
Maximum number
Go to Q5.11

5.11 Do you have any requirements or information that the enumerator will need when
they conduct the enumeration?
1

Yes – Specify below

2

No – Go to Section 6

Section 6 – APPOINTMENT INFORMATION
6.1

When can we conduct the enumeration at your facility?
Month
Day
Time

:
6.2

a.m.
p.m.

When the enumerator comes to conduct the enumeration, are you the person they
should speak with?
1
2

Yes – Go to Section 7
No – Specify name and title of person to contact
NAME

Area Code

TITLE

Telephone number

Extension

–

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FORM SC-351 (6-8-2012)

Section 7 – CLOSING THE INTERVIEW

Thank you very much for your time. We
have the enumeration of your facility
scheduled for
(Appointment date) at (Appointment time).
We will call you the day before to
remind you.

FORM SC-351 (6-8-2012)

Page 7