DH-61(ICQ) Individual Census Questionnaire-Informational Copy

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

Use blue or black pen.

Start here
1.

6.

What is your 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.

What is your name? Print name below.
First Name

MI

Irish

English

Italian

Polish

French

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

Do you live or stay here most of the time?
Yes

3.

German

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

Last Name(s)

2.

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

No

Besides here, what is the full address of a place
where you sometimes live or stay?

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

I never stay at any other place. I only live here.
Address Number (For example: 5007)

L
A

BLACK OR AFRICAN AMERICAN – Provide details below.

T

African
American
Nigerian

Street Name (For example: N Maple Ave)

N
O

Jamaican

Haitian

Ethiopian

Somali

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

AF

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

M
R

R

Rural Route Address (if there is no street address)

O
F

D

IN

City

State

I
T

ZIP Code

➜ NOTE: Please provide a location description below if there is no
address or if this is a facility.

A

ASIAN – Provide details below.
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.

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Moroccan

Israeli

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

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.

4.

Male

5.

Female

Samoan

Chamorro

Fijian

Marshallese

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

What is your age and what is your 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
years

FORM

Native
Hawaiian
Tongan

What is your sex? Mark I
J
K ONE box.

DH-61(ICQ) (05-03-2017)

Print numbers in boxes.
Month
Day

Year of birth

SOME OTHER RACE OR ETHNICITY – Print details.

11568011

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2018 Individual Census
Questionnaire

DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

A message from the Director, U.S. Census Bureau
This is your Individual Census Questionnaire for the 2018 Census Test. The Census Bureau is
researching modern and cost-efficient methods for the population to exercise its civic obligation to be
counted in the 2020 Census. By completing this Individual Census Questionnaire, you help prepare
for a more accurate count of all populations in the 2020 Census.

T

This Individual Census Questionnaire is to be used to count people who were living or staying
in group quarters on Census Day. Some examples of group quarters include college or university
residence halls, nursing homes, group homes, residential treatment centers, workers’ group living
quarters, and correctional facilities. Please answer ALL of the questions on this questionnaire,
and then follow the instructions you were given when you received this questionnaire in order
to return it to the appropriate person. You are required by law to respond to the census (Title 13,
U.S. Code, Sections 141, 193, 221, and 223).

N
O

L
A

The Census Bureau is required by law to protect your information. The Census Bureau is not
permitted to publicly release your responses in a way that could identify you. By law, the Census Bureau
can only use your responses to produce statistics. Per the Federal Cybersecurity Enhancement Act of
2015, your data are protected from cybersecurity risks through screening of the systems that transmit
your data. For more information about how we protect your information, please visit our website at
census.gov, and at the bottom of the home page, click on “Data Protection and Privacy Policy.”

AF

I
T

John H. Thompson
Director

M
R

A

R

Sincerely,

D

IN

O
F

Thank you for completing your 2018 Individual Census Questionnaire.
FOR OFFICIAL USE ONLY
The 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.

GQ Control Number

A. PN
B. Answered By:

C. QC:

FORM DH-61(ICQ) (05-03-2017)

Rework

Respondent

Group Quarters
Administrator

Observation
(TNSOLs only)

Other

11568029

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