Download:
pdf |
pdf§,n!.¤
OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
TM
Transitory Locations Questionnaire
FOR NPC
USE ONLY
Case ID
ACO
State
Block
ns
h
Map Spot
➤
➤
APPLY LABEL HERE
ip
Tract
County
Are there any continuation questionnaires for this address?
Yes ➜ Number of continuation questionnaires =
Hello, I am (name) from the U.S. Census Bureau (show ID).
Are you currently living or staying in this
[RV/boat/room/unit]? If respondent says no, ask, “Is there
someone available that I can talk to who currently lives or
stays in this [RV/boat/room/unit]?”
S4.
Is this [RV/boat/room/unit]
Mark K
J ONE box.
I
iti
S1.
ze
No
Owned by you or someone in this household with a
mortgage or loan, including home equity loans?
Owned by you or someone in this household free and
clear, without a mortgage or loan?
I am here to complete a 2020 Census questionnaire for
this [RV/boat/room/unit]. It should take about 10 minutes
(hand respondent a confidentiality notice). This notice explains
that your answers are confidential. Do all of the people
who are staying in this [RV/boat/room/unit] have another
place where they usually live?
Yes
Rented?
Occupied without payment of rent?
S5.
N
o
S2.
C
Respondent confirmed that he or she lives or stays in this
[RV/boat/room/unit].
Please read the WHO TO COUNT section on the
Information Sheet (hand respondent an information sheet,
and pause to allow the respondent to read it). Based on
these instructions, how many people are currently living
or staying in this [RV/boat/room/unit]?
No – Skip to S4.
ft:
S3.
Number of people =
Will all of the people staying in this [RV/boat/room/unit]
return to the place where they usually live by May 5, 2020?
ra
Yes – Please respond to the 2020 Census for that other
place to ensure you will be counted there (hand respondent
a notice of visit). Thank you for your time! – Skip to page 16.
D
No
FORM
D-Q-TL (02-05-2019) Draft 33
11770013
§,n!6¤
Person 1
1.
5.
Now I am going to ask you questions about each person
staying here. If there is someone staying here who pays the
rent or owns this [RV/boat/room/unit], I would like to start
by listing him or her as Person 1. If the owner or the person
who pays the rent is not staying here, I can start by listing
any adult staying here as Person 1.
Please read the RACE section on the Information Sheet.
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 and verify the spelling.
First Name
MI
ip
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Last Name(s)
ns
h
2.
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
Is Person 1 male or female? Mark K
J ONE box.
I
Male
Female
What was Person 1’s age on April 1, 2020? What is Person 1’s
date of birth? If you don’t know the exact age, please estimate.
For babies less than 1 year old, do not report the age in months.
Report 0 as the age.
Print numbers in boxes.
Month
Day
Age on April 1, 2020
Year of birth
o
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
N
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is Person 1 of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
ft:
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
ra
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
D
4.
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
C
years
2
11770021
Native Hawaiian
Filipino
iti
3.
Vietnamese
ze
Chinese
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n!H¤
Person 1
6.
Does Person 1 usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 2, if there is another person.
7.
What is the full address of the place where Person 1 lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 2 on the next page.
3
11770039
§,n!P¤
Person 2
1.
6.
What is Person 2’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
4
11770047
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n!W¤
Person 2
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 3, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 3 on the next page.
5
11770054
§,n!_¤
Person 3
1.
6.
What is Person 3’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
6
11770062
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n!g¤
Person 3
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 4, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 4 on the next page.
7
11770070
§,n!y¤
Person 4
1.
6.
What is Person 4’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
8
11770088
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n!£¤
Person 4
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 5, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 5 on the next page.
9
11770096
§,n"%¤
Person 5
1.
6.
What is Person 5’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
10
11770104
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n"-¤
Person 5
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 6, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 6 on the next page.
11
11770112
§,n"5¤
Person 6
1.
6.
What is Person 6’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
12
11770120
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n"G¤
Person 6
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 7, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more people were counted in Question S5 on the
front page, continue with Person 7 on the next page.
13
11770138
§,n"O¤
Person 7
1.
6.
What is Person 7’s name?
Print name below and verify the spelling.
First Name
MI
Please read the RACE section on the Information Sheet.
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)
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
ns
h
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
C
Female
What was this person’s age on April 1, 2020? What is this
person’s date of birth? If you don’t know the exact age, please
estimate. For babies less than 1 year old, do not report the age in
months. Report 0 as the age.
Print numbers in boxes.
Month
Day
Year of birth
N
Age on April 1, 2020
years
ft:
➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
ra
Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
D
5.
Vietnamese
ze
Chinese
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C
14
11770146
Native Hawaiian
Filipino
Korean
Samoan
Asian Indian
Japanese
Chamorro
Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C
Is this person male or female? Mark K
J ONE box.
I
Male
4.
ip
Opposite-sex husband/wife/spouse
iti
3.
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C
Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I
o
2.
Some other race – Print race or origin. C
Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C
§,n"V¤
Person 7
7.
Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Start with Person 8 on the continuation
questionnaire, if there is another person.
8.
What is the full address of the place where this person lives
or stays most of the time?
ip
Address Number (For example: 5007)
ns
h
Street Name (For example: N Maple Ave)
ze
Apt/Unit (For example: Apt A or Lot 3)
iti
Rural Route Address (if there is no street address)
ZIP Code
o
State
C
City
➜ NOTE: Please provide a location description if there is no address
D
ra
ft:
N
or if this is a facility.
➜ If more than 7 people were counted in Question S5,
continue with the next person on the Continuation
Questionnaire (D-CQ-TL), and update number of
continuation questionnaires on page 1.
15
11770153
§,n"^¤
OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
RESPONDENT INFORMATION
R1. What is your name? Print name below and verify the spelling.
First Name
R2. What is your telephone number? We will only contact
you if needed for official Census Bureau business.
MI
Telephone Number
–
–
Last Name(s)
R3. To confirm: Do you
Currently live or stay in this [RV/boat/room/unit]?
INTERVIEW SUMMARY
B.
Language Code =
Number of people
listed on questionnaire(s) =
ns
h
A.
ip
Not live or stay in this [RV/boat/room/unit]
(neighbor or other proxy)?
01 – 99 = Total people
JIC2
ze
JIC1
RECORD OF CONTACT
✗
MM
In-Person
DD
HH
MM
/
Outcome
Type
a.m.
:
MM
In-Person
DD
/
HH
MM
Outcome
a.m.
:
iti
Type
p.m.
p.m.
Telephone
C
OUTCOME CODES: CI = Conducted Interview PR = Partial Refusal NE= Not Eligible for Full Interview (S3=Yes)
CONFIRM LOCATION AND UNIT DESIGNATION
Unit Designation
o
Address Number
City
D
ra
Location Description
ft:
N
Street Name or Rural Route Address
State
ZIP Code
CERTIFICATION
CFS Initials
I certify that the entries I have made on this questionnaire are true
and correct to the best of my knowledge.
Enumerator’s Signature
Month
Employee ID
Day
CFSD Number
Month
16
11770161
Day
| File Type | application/pdf |
| File Modified | 2019-02-08 |
| File Created | 2019-01-23 |