D-Q-GERA Individual Census Questionnaire Remote Alaska

Please do NOT photocopy this questionnaire. Each questionnaire has a unique ID number.

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

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Use a blue or black pen.

Start here
1.

What is your name? Print name below.
First Name

➜ NOTE: Please answer BOTH Question 6 about Hispanic
origin and Question 7 about race. For this census, Hispanic
origins are not races.

6.

MI

Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican

Last Name(s)

Yes, Cuban

Yes

3.

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Do you live or stay here most of the time?
No

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

7.

I never stay at any other place. I only live here.

What is your race?
Mark K
J one or more boxes AND print origins.
I

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2.

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

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Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

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Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

C

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

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

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Rural Route Address (if there is no street address)

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City

ZIP Code

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State

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

4.

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

5.

Female

What will your age be on April 1, 2020, and what is your date
of birth? If you don’t know the exact age, please estimate. For babies
less than 1 year old, do not write the age in months. Write 0 as the age.
Print numbers in boxes.
Age on April 1, 2020
Month
Day
Year of birth
years

FORM

D-Q-GERA (01-16-2019) Draft 4

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Some other race – Print race or origin. C

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

11850021

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Individual Census Questionnaire

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

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

This is your Individual Census Questionnaire for the 2020 Census. We need your help to count everyone in the
United States. It is important that everyone be counted, regardless of where they may be living at the time of the
census. Results from the 2020 Census will be used to help determine the distribution of funding for community
services. By completing this Individual Census Questionnaire, you help ensure an accurate count of all populations
in the 2020 Census.

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This Individual Census Questionnaire is to be used to count people who will be living, staying or receiving services
in group quarters on April 1, 2020. 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. 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).

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The Census Bureau is required by law to protect your information (Title 13, U.S. Code, Section 9). The Census
Bureau is not permitted to publicly release your responses in a way that could identify anyone. We are conducting
the 2020 Census under the authority of Title 13, U.S. Code, Sections 141, 193, 221 and 223. 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.

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Title 13 of the U.S. Code protects the confidentiality of all your information. Violating the confidentiality of a
respondent is a federal crime with serious penalties, including a federal prison sentence of up to five years, a fine of
up to $250,000, or both. Only authorized individuals have access to the stored data, and the information you
provide to the Census Bureau may only be used by a restricted number of authorized individuals who are sworn for
life to protect the confidentiality of your individual responses. Your answers cannot be used against you by any
government agency or court.

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For more information about how we protect your information, please visit our Web site at census.gov and click on
"Data Protection and Privacy Policy" at the bottom of the home page. This page also includes information about the
collection, storage, and use of these records. Click on "System of Records Notices (SORN)" and look for Privacy
Act System of Records Notice COMMERCE/CENSUS-5, Decennial Census Program.

Thank you for completing your 2020 Individual Census Questionnaire.

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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 the census.

GQ Control Number

A. PN
B. Answered By:

C. QC:
FORM D-Q-GERA (01-16-2019) Draft 4

Rework

Respondent

Group Quarters
Administrator

Observation
(TNSOLs only)

Other

11850013

DC

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

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Please do NOT photocopy this questionnaire. Each questionnaire has a unique ID number.