DH-1(UL) English Paper Questionnaire

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

2018 Census Test

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

FOR
OFFICIAL
USE ONLY

FOR OFFICIAL USE ONLY

Address Number (For example: 5007)

T

Street Name (For example: N Maple Ave) or Rural Route Address

Start here

ZIP Code

R
AF

Apt/Unit (For example: Apt A or Lot 3)

OR go online at survey.census.gov to complete the 2018 Census Test.

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 April 1, 2018
that you did not include in Question 1?
J
Mark I
K all that apply.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

D

• 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 survey.census.gov or call the number on page 8.

Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily

The census must also include people without a permanent
place to live, so:

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.

The Census Bureau also conducts counts in institutions and
other places, so:

Owned by you or someone in this household free and clear
(without a mortgage or loan)?

• 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 April 1, 2018.
• 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.

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

1.

How many people were living or staying in this house,
apartment, or mobile home on April 1, 2018?

–

Number of people =
FORM

DH-1(UL) (05-24-2017) Draft 15

–

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11538014

• If someone who does not have a permanent place to live is
staying here on April 1, 2018, count that person.

No additional people

Person 1
5.

8.

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.

Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

What is Person 1’s name? Print name below.
First Name

What is Person 1’s race or ethnicity?

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.
MI

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

Last Name(s)

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

What is Person 1’s sex? Mark K
J ONE box.
I
Male

7.

Female

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

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, 2018

Print numbers in boxes.
Month
Day

Jamaican

Haitian

Ethiopian

Somali

T

6.

Print, for example, Ghanaian, South African, Barbadian, etc.

Year of birth

R
AF

ASIAN – Provide details below.

years

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

D

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

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Print, for example, Algerian, Iraqi, Kurdish, etc.

Native
Hawaiian
Tongan

Samoan

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

➜ If more people were counted in Question 1 on
the front page, continue with Person 2 on the
next page.

2

11538022

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.

1.

Person 2

Print name of

6.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

2.

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

No
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

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse

Same-sex husband/wife/spouse

R
AF

Stepson or stepdaughter
Brother or sister

Somali

ASIAN – Provide details below.

Same-sex unmarried partner

Adopted son or daughter

Haitian

Ethiopian

Print, for example, Ghanaian, South African, Barbadian, etc.

Opposite-sex unmarried partner

Biological son or daughter

Jamaican

T

3.

Yes, for college

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

Father or mother
Grandchild

D

Parent-in-law

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Son-in-law or daughter-in-law
Other relative

Roommate or housemate

Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

Print, for example, Algerian, Iraqi, Kurdish, etc.

11538030

Other nonrelative

4.

What is this person’s sex? Mark K
J ONE box.
I
Male

5.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Female

Print numbers in boxes.
Month
Day

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

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, 2018

Samoan

SOME OTHER RACE OR ETHNICITY – Print details.

Year of birth

years

➜ If more people were counted in Question 1 on
the front page, continue with Person 3 on the
next page.

3

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Foster child

1.

Person 3

Print name of

6.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

2.

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

No
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

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse

Same-sex husband/wife/spouse

Adopted son or daughter
Stepson or stepdaughter
Brother or sister

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

Father or mother
Grandchild

D

Parent-in-law

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Son-in-law or daughter-in-law
Other relative

Somali

ASIAN – Provide details below.

R
AF

Biological son or daughter

Haitian

Ethiopian

Print, for example, Ghanaian, South African, Barbadian, etc.

Opposite-sex unmarried partner

Same-sex unmarried partner

Jamaican

T

3.

Yes, for college

Roommate or housemate

Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

Print, for example, Algerian, Iraqi, Kurdish, etc.

Other nonrelative

4.

What is this person’s sex? Mark K
J ONE box.
I
Male

5.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Female

Print numbers in boxes.
Month
Day

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

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, 2018

Samoan

SOME OTHER RACE OR ETHNICITY – Print details.

Year of birth

years

➜ If more people were counted in Question 1 on
the front page, continue with Person 4 on the
next page.

4

11538048

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Foster child

1.

Person 4

Print name of

6.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

2.

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

No
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

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse

Same-sex husband/wife/spouse

R
AF

Stepson or stepdaughter
Brother or sister

Somali

ASIAN – Provide details below.

Same-sex unmarried partner

Adopted son or daughter

Haitian

Ethiopian

Print, for example, Ghanaian, South African, Barbadian, etc.

Opposite-sex unmarried partner

Biological son or daughter

Jamaican

T

3.

Yes, for college

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

Father or mother
Grandchild

D

Parent-in-law

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Son-in-law or daughter-in-law
Other relative

Roommate or housemate

Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

Print, for example, Algerian, Iraqi, Kurdish, etc.

11538055

Other nonrelative

4.

What is this person’s sex? Mark K
J ONE box.
I
Male

5.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Female

Print numbers in boxes.
Month
Day

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

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, 2018

Samoan

SOME OTHER RACE OR ETHNICITY – Print details.

Year of birth

years

➜ If more people were counted in Question 1 on
the front page, continue with Person 5 on the
next page.

5

§,VqX¤

Foster child

1.

Person 5

Print name of

6.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

2.

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

No
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

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse

Same-sex husband/wife/spouse

Adopted son or daughter
Stepson or stepdaughter
Brother or sister

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

Father or mother
Grandchild

D

Parent-in-law

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Son-in-law or daughter-in-law
Other relative

Somali

ASIAN – Provide details below.

R
AF

Biological son or daughter

Haitian

Ethiopian

Print, for example, Ghanaian, South African, Barbadian, etc.

Opposite-sex unmarried partner

Same-sex unmarried partner

Jamaican

T

3.

Yes, for college

Roommate or housemate

Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

Print, for example, Algerian, Iraqi, Kurdish, etc.

Other nonrelative

4.

What is this person’s sex? Mark K
J ONE box.
I
Male

5.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Female

Print numbers in boxes.
Month
Day

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

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, 2018

Samoan

SOME OTHER RACE OR ETHNICITY – Print details.

Year of birth

years

➜ If more people were counted in Question 1 on
the front page, continue with Person 6 on the
next page.

6

11538063

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Foster child

1.

Person 6

Print name of

6.

First Name

MI

What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
WHITE – Provide details below.

Last Name(s)

German

Irish

English

Italian

Polish

French

Print, for example, Scottish, Norwegian, Dutch, etc.

2.

Does this person usually live or stay somewhere else?
Mark K
J all that apply.
I

HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican
Puerto
or Mexican
Cuban
Rican
American
Salvadoran
Dominican
Colombian

No
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

Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

BLACK OR AFRICAN AMERICAN – Provide details below.
African
American
Nigerian

How is this person related to Person 1? Mark K
J ONE box.
I
Opposite-sex husband/wife/spouse

Same-sex husband/wife/spouse

R
AF

Stepson or stepdaughter
Brother or sister

Somali

ASIAN – Provide details below.

Same-sex unmarried partner

Adopted son or daughter

Haitian

Ethiopian

Print, for example, Ghanaian, South African, Barbadian, etc.

Opposite-sex unmarried partner

Biological son or daughter

Jamaican

T

3.

Yes, for college

Chinese

Filipino

Asian Indian

Vietnamese

Korean

Japanese

Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.

Father or mother
Grandchild

D

Parent-in-law

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Son-in-law or daughter-in-law
Other relative

Roommate or housemate

Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

Print, for example, Algerian, Iraqi, Kurdish, etc.

11538071

Other nonrelative

4.

What is this person’s sex? Mark K
J ONE box.
I
Male

5.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
Native
Hawaiian
Tongan

Female

Print numbers in boxes.
Month
Day

Chamorro

Fijian

Marshallese

Print, for example, Palauan, Tahitian, Chuukese, etc.

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, 2018

Samoan

SOME OTHER RACE OR ETHNICITY – Print details.

Year of birth

years

➜ If more people were counted in Question 1 on
the front page, continue with Person 7 on the
next page.

7

§,Vqh¤

Foster child

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

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 April 1, 2018
Male

Female

Month

Day

Year of birth

years

Related to Person 1?
Yes

No

Person 8
First Name

MI

Last Name(s)

Date of Birth
Age on April 1, 2018
Male

Female

Month

years

Person 9
MI

Year of birth

Related to Person 1?
Yes

No

Last Name(s)

R
AF

First Name

Day

T

Sex

Date of Birth

Sex

Age on April 1, 2018
Male

Female

Person 10

Sex

MI

Age on April 1, 2018

Male

Female

Day

Year of birth

years

D

First Name

Month

Related to Person 1?
Yes

No

Last Name(s)

Date of Birth
Month

Day

Year of birth

years

Related to Person 1?
Yes

No

Thank you for completing the 2018 Census Test.
If your enclosed postage-paid envelope is missing,
please mail your completed questionnaire to:

JIC1

JIC2

U.S. Census Bureau
National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

If you need help completing this questionnaire, call 1-844-330-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET. The telephone
call is free.
TDD — Telephone display device for the hearing impaired. Call 1-844-467-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET.
The telephone call is free.
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 xxxx-xxxx, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments
to <[email protected]>; use “Paperwork Reduction Project xxxx-xxxx” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit approval number that appears at the upper right of the
questionnaire confirms this approval. If this number were not displayed, we could not conduct this survey.

8

11538089

§,Vqz¤

FOR OFFICIAL USE ONLY