Introduction Screen
Thank you for agreeing to participate in this research study. On the next screen, you will be asked to begin filling out a questionnaire similar to what will be used in the 2020 Census. After you have filled out the questionnaire for yourself and one other person in your household, you will be asked to answer some follow-up questions about the previous question items.
By law, the Census Bureau is required to keep your answers confidential. This survey is voluntary and you may refuse to answer any question. The results of this study will be used to inform future surveys and censuses. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0978, confirms this approval. If this number was not displayed, we could not conduct this survey. We estimate that this survey will take about 15 minutes. By proceeding with this study, you give your consent to participate in this study.
Your privacy is protected by the Privacy Act. There are a limited number of uses of your data that are permitted under the Privacy Act. You can find a list of these uses in the System of Records Notice (SORN). For this survey, the SORN is named “COMMERCE/CENSUS-5, Decennial Census Program.” For more information, please visit our website at census.gov and click on "Data Protection and Privacy Policy" at the bottom of the home page.
Decennial Question items
This questionnaire is similar to what you might receive as part of the 2020 Census. Please answer the questions as you would if you were answering from the home where you live or stay most of the time.
How many people were living or staying in this house, apartment, or mobile home on April 1, 2019?
Number of people = ________
Were there any additional people staying here on April 1, 2019 that you did not include in Question 1? Mark x all that apply.
Children, related or unrelated, such as newborn babies, grandchildren, or foster children
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
No additional people
Is this house, apartment, or mobile home – Mark x ONE box.
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 or rent?
What is your telephone number? We will only contact you if needed for official Census Bureau business.
Telephone Number
__ __ __ - __ __ __- __ __ __ __
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.
For this survey, please consider yourself Person 1 and answer the questions as if you were Person 1.
What is person 1’s name? Print name below.
First Name MI
________________________________ ____
Last Name(s)
____________________________________________
What is Person 1’s sex? Mark x ONE box.
Male □ 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 April 1, 2019 Month Day Year of Birth
__ __ __ Years __ __ __ __ __ __ __ __
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.
________________________________________________
9. What is Person 1’s race?
Mark x one or more boxes AND print origins.
White – Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc.
_____________________________________________________________
Black or African Am. – Print, for example, African-American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.
_____________________________________________________________
American Indian OR Alaska Native – Print name or enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc.
_____________________________________________________________
□ Chinese □ Vietnamese □ Native Hawaiian
□ Filipino □ Korean □ Samoan
□ Asian Indian □ Japanese □ Chamorro
□ Other Asian-Print for example, □ Other Pacific Islander-
Pakistani, Cambodian, Hmong, etc. Print for example, Tongan, Fijan, Marshallese, etc.
___________________________________________________________
Some other race- Print race or origin
___________________________________________________________
10. What is the highest degree or level of school Person 1 has completed?
No high school
Some high school
High school graduate or equivalent (for example GED)
Some college, but degree not received or is in progress
Associate degree (for example AA, AS)
Bachelor’s degree (for example BA, BS, AB)
Graduate degree (for example master’s, professional, doctorate)
Note: If more people were counted in Question 1 on the front page, continue with Person 2.
1. Print name of Person 2.
First Name MI
________________________________ ____
Last Name(s)
____________________________________________
2. Does this person usually live or stay somewhere else?
Mark x all that apply
No
Yes, to 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
3. How is this person related to Person 1? Mark x ONE box.
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 non-relative
4. What is this person’s sex? Mark x ONE box.
Male □ Female
5. 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 April 1, 2019 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.
________________________________________________
7. What is this person’s race?
Mark x one or more boxes AND print origins.
White – Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc.
_____________________________________________________________
Black or African Am. – Print, for example, African-American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.
_____________________________________________________________
American Indian OR Alaska Native – Print name or enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc.
_____________________________________________________________
□ Chinese □ Vietnamese □ Native Hawaiian
□ Filipino □ Korean □ Samoan
□ Asian Indian □ Japanese □ Chamorro
□ Other Asian-Print for example, □ Other Pacific Islander-
Pakistani, Cambodian, Hmong, etc. Print for example, Tongan, Fijan, Marshallese, etc.
___________________________________________________________
Some other race- Print race or origin
___________________________________________________________
Thank you for your answers. Since this questionnaire is for testing and research purposes, we do not need detailed information about all members of your household. Now we will ask some questions about the information you just provided.
A subset of questions from Enclosure 4 will be selected and probes will be embedded. Probes may include items such as:
How did you come up with your answer?
What does the term “[FILL]” mean to you in this question?
Can you think of an example of “[PHRASE]”?
How easy or difficult was it to answer this question?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jessica Holzberg (CENSUS/CBSM FED) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |