Group Quarters

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Overview

GQE
MFV
SH
SK
TNSOL

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Sheet 1: GQE

THIS LISTING CONTAINS CONFIDENTIAL INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C., OMB NO. APPROVAL EXPIRES
D-352.1GQ (GQE)					U.S. Department of Commerce
					Economic and Statistics Administration
					U.S. Census Bureau
GROUP QUARTERS ENUMERATION RECORD
GROUP QUARTERS ENUMERATION
2018 CENSUS Test
RCC:
ACO:
GQ ID:
							||| BARCODE Number |||
GQ Name:							##### ### #### ##
Facility Name:											Items 1-28 and notes should be prepopulated
1. State:	2. County:		3. BCU No:		4. Map Spot No:		5. GQ Type Code:
6a. Street Number:		6b. Street Name:				6c. Apt/Unit:
7. Rural Route or P.O. Box Number:
8. City:						9. Zip Code:
10. Building Name:					11. Building Number:
12. Location Description:
13. GQ Contact Name:					14. GQ Contact Title:
15. GQ Contact Telephone Number:						16. Business Email:
17. Secondary Contact Name:					18. Secondary Contact Title:
19. Secondary Contact Telephone Number:						20. Max Pop:
21. Will this facility be operating on April 1, 2018? q Yes q No SEE NOTES SECTION
22. Expected Pop:		23. Are clients males only, females only, or both?				q Males q Females q Both
24. How will this facility be enumerated? *Only show the enumeration type selected in Advanced Contact*
Enumeration Types consist of:
In-Person Interview Drop off/Pick up Questionnaire Paper Response Data Transfer
Facility Self Enumeration (CORRECTIONAL FACILITIES & HOSPITALS ONLY) Electronic Response Data Transfer (eResponse)
25. Are there any people at this location that do not speak or understand English? q Yes q No
If yes - What language do they speak?
26. Enumeration appointment (Date & Time):
27. Any specific instructions Census staff need to know in order to count the people at this location?
qYes q No SEE NOTES SECTION
28. Do you have a roster available for our use during enumeration? q Yes q No
29. Can you or a staff member assist with the enumeration?					q Yes q No
30. Staff member name and telephone number:
Name ______________________________________________ Telephone ________________________________
NOTES SECTION
31. (Lead) Enumerator Name & ID:					32. Date Assigned (mm/dd/yy):
33. Date Enumeration Completed/Pick-up Date (mm/dd/yy):						34. # of ICQs (Census Day pop):
35. I certify that I have completed enumeration (Enumerator Signature):
36. For Supervisory Use Only:
q N q R q D-1 q D-2 Survivor ID# ___________ q V q O
Office Use Only: q Rework
####	THIS IS THE CONTROL NUMBER FOR THIS GROUP QUARTERS.							####
	YOUR MATERIALS FOR ENUMERATION INCLUDE LABELS
	PRINTED WITH THIS NUMBER.

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Sheet 2: MFV

THIS LISTING CONTAINS CONFIDENTIAL INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C., OMB NO. 0607-0919-C APPROVAL EXPIRES MM/DD/YYYY

D-352.1MFV (SBE)

U.S. Department of Commerce

(MM/DD/YYYY)

Economic and Statistics Administration

U.S. Census Bureau

REGULARLY SCHEDULED MOBILE FOOD VAN ENUMERATION RECORD

GROUP QUARTERS ENUMERATION

2018 CENSUS Test

RCC:

ACO:

GQ ID:

||| BARCODE Number |||

GQ Name:

##### ### #### ##

Facility Name:

1. State:

2. County:

3. BCU No:

4. Map Spot No:

5. GQ Type Code:

6a. Street Number:

6b. Street Name:

6c. Apt/Unit:

7. Rural Route or P.O. Box Number:

Items 1-26 and notes should be prepopulated

8. City:

9. Zip Code:

10. Location Description:

11. GQ Contact Name:

12. GQ Contact Title:

13. GQ Contact Telephone Number:

14. Secondary Contact Name:

15. Secondary Contact Title:

16. Secondary Contact Telephone Number:

17. Business Email:

18. Max Pop:

19. What are the major intersections of this stop?

20. Arrival and departure time of this stop?

Arrival Time Departure Time

21. Expected Pop:

____:____ a.m. ____:____ a.m.

____:____ p.m. ____:____ p.m.

22. Do clients stay near van? q Yes q No

23. Method of receiving food (i.e. line up, congregate, other): SEE NOTES SECTION

24. Enumeration appointment date and time:

q Wednesday, March 28

____:____ a.m.

____:____ p.m.

q Thursday, March 29

____:____ a.m.

____:____ p.m.

q Friday, March 30

____:____ a.m.

____:____ p.m.

25. Are there any people at this location that do not speak or understand English? q Yes q No

If yes - What language do they speak?

26. Any specific instructions Census staff need to know in order to count the people at this location?

qYes q No SEE NOTES SECTION

NOTES SECTION

25. (Lead) Enumerator Name & ID:

26. Date Assigned (mm/dd/yy):

27. I certify that I have completed enumeration (Enumerator Signature)

28. Date Enumeration Conducted (mm/dd/yy):

29. # of ICQs (Census Day pop):

30. For Supervisory Use Only:

q N q R q D-1 q D-2 Survivor ID# ___________ q V q O

####

THIS IS THE CONTROL NUMBER FOR THIS GROUP QUARTERS.

####

YOUR MATERIALS FOR ENUMERATION INCLUDE LABELS

PRINTED WITH THIS NUMBER.

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Sheet 3: SH

THIS LISTING CONTAINS CONFIDENTIAL INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C., OMB NO. 0607-0919-C APPROVAL EXPIRES MM/DD/YYYY

D-352.1SH (SBE)

U.S. Department of Commerce

(MM/DD/YYYY)

Economic and Statistics Administration

U.S. Census Bureau

SHELTER ENUMERATION RECORD

GROUP QUARTERS ENUMERATION

2018 CENSUS Test

RCC:

ACO:

GQ ID:

||| BARCODE Number |||

GQ Name:

##### ### #### ##

Facility Name:

1. State:

2. County:

3. BCU No:

4. Map Spot No:

5. GQ Type Code:

Items 1-29 and notes should be prepopulated

6a. Street Number:

6b. Street Name:

6c. Apt/Unit:

7. Rural Route or P.O. Box Number:

8. City:

9. Zip Code:

10. Building Name:

11. Building Number:

12. Location Description:

13. GQ Contact Name:

14. GQ Contact Title:

15. GQ Contact Telephone Number:

16. Business Email:

17. Secondary Contact Name:

18. Secondary Contact Title:

19. Secondary Contact Telephone Number:

20. Max Pop:

21. How early do clients arrive?

22. What is the earliest clients may enter?

23. Expected Pop:

___:___ a.m.

___:___ p.m.

___:___ a.m.

___:___ p.m.

24. Are clients males only, females only, or both?

25. What are the general procedures clients follow when they enter

q Males Only q Females Only q Both

the shelter? GO TO NOTES SECTION

26. Are there any people at this location that do not speak or understand English? q Yes q No

If yes - What language do they speak?

27. Any specific instructions Census staff need to know in order to count the people at this location?

qYes q No SEE NOTES SECTION

28. Enumeration appointment date and time:

q Wednesday, March 28

____:____ a.m.

____:____ p.m.

q Thursday, March 29

____:____ a.m.

____:____ p.m.

q Friday, March 30

____:____ a.m.

____:____ p.m.

29. Do you have a roster of clients that will be available for our use during enumeration? q Yes q No

30. Can a staff member assist with the enumeration? q Yes q No

31. Staff member name and telephone number:

Name _______________________________________________

Telephone ______________________________

NOTES SECTION

32. (Lead) Enumerator Name & ID:

33. Date Assigned (mm/dd/yy):

34. Date enumeration conducted (mm/dd/yy):

35. # of ICQs (Census Day pop):

36. For Supervisory Use Only:

q N q R q D-1 q D-2 Survivor ID# ___________ q V q O

####

THIS IS THE CONTROL NUMBER FOR THIS GROUP QUARTERS.

####

YOUR MATERIALS FOR ENUMERATION INCLUDE LABELS

PRINTED WITH THIS NUMBER.

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Sheet 4: SK

THIS LISTING CONTAINS CONFIDENTIAL INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C., OMB NO. 0607-0919-C APPROVAL EXPIRES MM/DD/YYYY

D-352.1SK (SBE)

U.S. Department of Commerce

(MM/DD/YYYY)

Economic and Statistics Administration

U.S. Census Bureau

SOUP KITCHEN ENUMERATION RECORD

GROUP QUARTERS ENUMERATION

2018 CENSUS Test

RCC:

ACO:

GQ ID:

||| BARCODE Number |||

GQ Name:

##### ### #### ##

Facility Name:

1. State:

2. County:

3. BCU No:

4. Map Spot No:

5. GQ Type Code:

Items 1-27 and notes should be prepopulated

6a. Street Number:

6b. Street Name:

6c. Apt/Unit:

7. Rural Route or P.O. Box Number:

8. City:

9. Zip Code:

10. Building Name:

11. Building Number:

12. Location Description:

13. GQ Contact Name:

14. GQ Contact Title:

15. GQ Contact Telephone Number:

16. Business Email:

17. Secondary Contact Name:

18. Secondary Contact Title:

19. Secondary Contact Telephone Number:

20. Max Pop:

20. Which meal serves the largest number of people?

q Breakfast q Lunch q Dinner

21. At what time is this meal served?

22. Expected pop at this meal?

23. At what time do clients assemble for this meal?

____:____ a.m. ____:____ p.m.

____:____ a.m. ____:____ p.m.

24. Method of receiving food (i.e. line up, congregate, other): SEE NOTES SECTION

25. Are there any people at this location that do not speak or understand English? q Yes q No

If yes - What language do they speak?

26. Enumeration appointment date and time:

q Wednesday, March 28

____:____ a.m.

____:____ p.m.

q Thursday, March 29

____:____ a.m.

____:____ p.m.

q Friday, March 30

____:____ a.m.

____:____ p.m.

27. Any specific instructions Census staff need to know in order to count the people at this location?

qYes q No SEE NOTES SECTION

28. Can a staff member assist with the enumeration? q Yes q No

29. Staff member name and telephone number:

Name ______________________________________________

Telephone ______________________________

NOTES SECTION

30. (Lead) Enumerator Name & ID:

31. Date Assigned (mm/dd/yy):

32. Date enumeration conducted (mm/dd/yy):

33. # of ICQs (Census Day pop):

34. For Supervisory Use Only:

q N q R q D-1 q D-2 Survivor ID# ___________ q V q O

####

THIS IS THE CONTROL NUMBER FOR THIS GROUP QUARTERS.

####

YOUR MATERIALS FOR ENUMERATION INCLUDE LABELS

PRINTED WITH THIS NUMBER.

---

Sheet 5: TNSOL

THIS LISTING CONTAINS CONFIDENTIAL INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C., OMB NO. 0607-0919-C APPROVAL EXPIRES MM/DD/YYYY

D-352.1TNSOL (SBE)

U.S. Department of Commerce

(MM/DD/YYYY)

Economic and Statistics Administration

U.S. Census Bureau

TARGETED NONSHELTERED OUTDOOR LOCATION ENUMERATION RECORD

GROUP QUARTERS ENUMERATION

2018 CENSUS Test

RCC:

ACO:

GQ ID:

||| BARCODE Number |||

GQ Name:

##### ### #### ##

Facility Name:

1. State:

2. County:

3. BCU No:

4. Map Spot No:

5. GQ Type Code:

6a. Street Number:

6b. Street Name:

Items 1-21 and notes should be prepopulated

7. Rural Route or P.O. Box Number:

8. City:

9. Zip Code:

10. Location Description:

11. GQ Contact Name:

12. GQ Contact Title:

13. GQ Contact Telephone Number:

14. Secondary Contact Name:

15. Secondary Contact Title:

16. Secondary Contact Telephone Number:

17. Hours location is occupied between 12:00 a.m. to 7:00 a.m.:

From

To

_____:_____ a.m.

_____:_____ a.m.

18. Expected Pop:

19. Security issues: q Yes SEE NOTES SECTION q No

20. Are there any people at this location that do not speak or understand English? q Yes q No

If yes - What language do they speak?

21. Any specific instructions Census staff need to know in order to count the people at this location?

qYes q No SEE NOTES SECTION

NOTES SECTION

22. (Lead) Enumerator Name & ID:

23. Date Assigned (mm/dd/yy):

24. Date enumeration conducted (mm/dd/yy):

25. # of ICQs (Census Day pop):

26. For Supervisory Use Only:

q N q R q D-1 q D-2 Survivor ID# ___________ q V q O

####

THIS IS THE CONTROL NUMBER FOR THIS GROUP QUARTERS.

####

YOUR MATERIALS FOR ENUMERATION INCLUDE LABELS

PRINTED WITH THIS NUMBER.