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OMB No. 0607-0936: Approval Expires 08/31/2021
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
2019 Census Test
FOR
OFFICIAL
USE ONLY
Start here
OR go online at respond.census.gov/2019CensusTest to complete your 2019 Census Test questionnaire.
Use a blue or black pen.
2.
Before you answer Question 1, count the people living in
this house, apartment, or mobile home using our
guidelines.
Were there any additional people staying here on
July 1, 2019 that you did not include in Question 1?
Mark I
K all that apply.
J
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children
• Count all people, including babies, who live and sleep
here most of the time.
• If no one lives and sleeps at this address most of the time,
go online at respond.census.gov/2019CensusTest or call
the number on page 8.
The census must also include people without a permanent
place to live, so:
• If someone who does not have a permanent place to live
is staying here on July 1, 2019, count that person.
The Census Bureau also conducts counts in institutions
and other places, so:
• Do not count anyone living away from here, either at
college or in the Armed Forces.
• Do not count anyone in a nursing home, jail, prison,
detention facility, etc., on July 1, 2019.
• Leave these people off your questionnaire, even if they
will return to live here after they leave college, the nursing
home, the military, jail, etc. Otherwise, they may be
counted twice.
1.
How many people were living or staying in this house,
apartment, or mobile home on July 1, 2019?
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
No additional people
3.
Is this house, apartment, or mobile home —
Mark K
J ONE box.
I
Owned by you or someone in this household with a mortgage
or loan? Include home equity loans.
Owned by you or someone in this household free and clear
(without a mortgage or loan)?
Rented?
Occupied without payment of rent?
4.
What is your telephone number?
We will only contact you if needed for official Census Bureau
business.
Telephone Number
–
Number of people =
FORM
DM-QB (12-11-2018)
13729017
–
§.i{:¤
Person 1
5.
9.
Please provide information for each person living here.
If there is someone living here who pays the rent or
owns this residence, start by listing him or her as
Person 1. If the owner or the person who pays the rent
does not live here, start by listing any adult living here
as Person 1.
What is Person 1’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
What is Person 1’s name? Print name below.
First Name
MI
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Last Name(s)
6.
What is Person 1’s sex? Mark K
J ONE box.
I
Male
7.
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Female
What is Person 1’s age and what is Person 1’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Year of birth
Chamorro
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
years
Some other race – Print race or origin. C
➜ NOTE: Please answer BOTH Question 8 about Hispanic
origin and Question 9 about race. For this census,
Hispanic origins are not races.
8.
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 2 on the
next page.
2
13729025
§.i{B¤
1.
Person 2
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No
3.
4.
Yes, for college
Yes, with a parent or
other relative
Yes, for a military assignment
Yes, at a seasonal or
second residence
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Father or mother
Opposite-sex unmarried partner
Grandchild
Same-sex husband/wife/spouse
Parent-in-law
Same-sex unmarried partner
Son-in-law or
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roommate or housemate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Female
What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Year of birth
years
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census,
Hispanic origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 3 on the
next page.
3
13729033
§.i{J¤
1.
Person 3
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No
Yes, for college
Yes, with a parent or
other relative
Yes, for a military assignment
Yes, at a seasonal or
second residence
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Chinese
3.
4.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Father or mother
Opposite-sex unmarried partner
Grandchild
Same-sex husband/wife/spouse
Parent-in-law
Same-sex unmarried partner
Son-in-law or
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roommate or housemate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
Vietnamese
Female
What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Year of birth
years
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census,
Hispanic origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 4 on the
next page.
4
13729041
§.i{[¤
1.
Person 4
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No
3.
4.
Yes, for college
Yes, with a parent or
other relative
Yes, for a military assignment
Yes, at a seasonal or
second residence
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Father or mother
Opposite-sex unmarried partner
Grandchild
Same-sex husband/wife/spouse
Parent-in-law
Same-sex unmarried partner
Son-in-law or
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roommate or housemate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Female
What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Year of birth
years
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census,
Hispanic origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 5 on the
next page.
5
13729058
§.i{c¤
1.
Person 5
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No
Yes, for college
Yes, with a parent or
other relative
Yes, for a military assignment
Yes, at a seasonal or
second residence
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Chinese
3.
4.
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Father or mother
Opposite-sex unmarried partner
Grandchild
Same-sex husband/wife/spouse
Parent-in-law
Same-sex unmarried partner
Son-in-law or
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roommate or housemate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
Vietnamese
Female
What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Year of birth
years
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census,
Hispanic origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 6 on the
next page.
6
13729066
§.i{k¤
1.
Person 6
Print name of
7.
First Name
MI
What is this person’s race?
Mark K
J one or more boxes AND print origins.
I
White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C
Last Name(s)
2.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I
No
3.
4.
Yes, for college
Yes, with a parent or
other relative
Yes, for a military assignment
Yes, at a seasonal or
second residence
Yes, for a job or business
Yes, in a jail or prison
Yes, in a nursing home
Yes, for another reason
How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse
Father or mother
Opposite-sex unmarried partner
Grandchild
Same-sex husband/wife/spouse
Parent-in-law
Same-sex unmarried partner
Son-in-law or
daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roommate or housemate
Stepson or stepdaughter
Foster child
Brother or sister
Other nonrelative
Chinese
Vietnamese
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
Some other race – Print race or origin. C
What is this person’s sex? Mark K
J ONE box.
I
Male
5.
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C
Female
What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Age on July 1, 2019
Print numbers in boxes.
Month
Day
Year of birth
years
➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census,
Hispanic origins are not races.
6.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
➜ If more people were counted in Question 1 on
the front page, continue with Person 7 on the
next page.
7
13729074
§.i{s¤
Use this section to complete information for the rest of the people you counted in Question 1 on the front page.
We may call for additional information about them.
Person 7
First Name
MI
Last Name(s)
Date of Birth
Sex
Age on July 1, 2019
Male
Month
Day
Year of birth
Related to Person 1?
years
Female
Yes
No
Person 8
First Name
MI
Last Name(s)
Date of Birth
Sex
Age on July 1, 2019
Male
Female
Month
Day
Year of birth
Related to Person 1?
years
Yes
No
Person 9
First Name
MI
Last Name(s)
Date of Birth
Sex
Age on July 1, 2019
Male
Female
Month
Day
Year of birth
Related to Person 1?
years
Yes
No
Person 10
First Name
MI
Last Name(s)
Date of Birth
Sex
Age on July 1, 2019
Male
Female
Month
Day
Year of birth
Related to Person 1?
years
Yes
No
FOR OFFICIAL USE ONLY
Thank you for completing your questionnaire.
If your enclosed postage-paid envelope is missing,
please mail your completed questionnaire to:
JIC1
JIC2
U.S. Census Bureau
National Processing Center
P.O. Box 5220
Jeffersonville, IN 47199-5220
If you need help completing this questionnaire, call toll-free 1-866-208-8248, Monday through Friday from 9:00 a.m. to midnight ET,
Saturday from 9:00 a.m. to 10:00 p.m. ET, and Sunday from 11:00 a.m. to midnight ET.
TDD — Telephone display device for the hearing impaired. Call toll-free 1-800-582-8330, Monday through Friday from 9:00 a.m. to midnight ET,
Saturday from 9:00 a.m. to 10:00 p.m. ET, and Sunday from 11:00 a.m. to midnight ET.
The U.S. Census Bureau estimates that completing the questionnaire will take 10 minutes on average. Send comments regarding this burden estimate or any
other aspect of this burden to: Paperwork Reduction Project 0607-0936, U.S. Census Bureau, ADDC-4H277, 4600 Silver Hill Road, Washington, DC 20233.
You may email comments to . Use “Paperwork Reduction Project 0607-0936” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number 0607-0936 confirms
this approval. If this number were not displayed, we could not conduct this survey.
8
13729082
| File Type | application/pdf |
| File Modified | 2019-06-28 |
| File Created | 2018-12-18 |