Form 1 Screener Card

Option 1: One-stage approach with response options

How many children 0-17 years old usually live or stay at this address?

• 1

• 2

• 3

• 4 or more

• none

Mailing Instructions: Thank you. Place this card in the postage-paid envelope provided.

If the envelope has been misplaced, please mail this card to:

U.S. Census Bureau

ATTN: DCB 60-A

1201 E. 10th Street

Jeffersonville, IN 47132-0001

Public reporting burden for this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 0607-0990, U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0990" as the subject.

You may also call 1-800-845-8241 to request a replacement envelope.

OMB No. 0607-0990: Approval Expires 05/31/2019

Option 2: Two-stage approach with response options

1. Are there any children 0-17 years old that usually live or stay at this address?

• Yes

• No  SKIP to Mailing Instructions

2. How many children 0-17 years old usually live or stay at this address?

• 1

• 2

• 3

• 4 or more

Mailing Instructions: Thank you. Place this card in the postage-paid envelope provided.

If the envelope has been misplaced, please mail this card to:

U.S. Census Bureau

ATTN: DCB 60-A

1201 E. 10th Street

Jeffersonville, IN 47132-0001

Public reporting burden for this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Paperwork Project 0607-0990, U.S. Census Bureau, 4600 Silver Hill Road, Room 8H590, Washington, DC 20233. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0990" as the subject.

You may also call 1-800-845-8241 to request a replacement envelope.

OMB No. 0607-0990: Approval Expires 05/31/2019

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