D-Q-TLRA Transitory Locations Questionnaire Remote Alaska

§,w!-¤

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]?”

S3.

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?

S4.

Yes – Please respond to the 2020 Census for that other
place to ensure you will be counted there.
Thank you for your time! – Skip to page 16.

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]?

ft:

Number of people =

D

ra

No

Rented?
Occupied without payment of rent?

N

o

S2.

C

Respondent confirmed that he or she lives or stays in this
[RV/boat/room/unit].

FORM

D-Q-TLRA (02-05-2019) Draft 11

11860012

§,w!5¤
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 will Person 1’s age be 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

11860020

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

§,w!G¤
Person 1
7.

Does Person 1 usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 2, if there is another person.

8.

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 S4 on the
front page, continue with Person 2 on the next page.

3

11860038

§,w!O¤
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 will this person’s age be 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

11860046

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

§,w!V¤
Person 2
8.

Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 3, if there is another person.

9.

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 S4 on the
front page, continue with Person 3 on the next page.

5

11860053

§,w!^¤
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 will this person’s age be 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

11860061

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

§,w!p¤
Person 3
8.

Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 4, if there is another person.

9.

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 S4 on the
front page, continue with Person 4 on the next page.

7

11860079

§,w!x¤
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 will this person’s age be 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

11860087

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

§,w!¢¤
Person 4
8.

Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 5, if there is another person.

9.

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 S4 on the
front page, continue with Person 5 on the next page.

9

11860095

§,w"$¤
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 will this person’s age be 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

11860103

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

§,w",¤
Person 5
8.

Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 6, if there is another person.

9.

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 S4 on the
front page, continue with Person 6 on the next page.

11

11860111

§,w">¤
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 will this person’s age be 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

11860129

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

§,w"F¤
Person 6
8.

Does this person usually live or stay somewhere else, other
than this location?
Yes
No – Skip to Person 7, if there is another person.

9.

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 S4 on the
front page, continue with Person 7 on the next page.

13

11860137

§,w"N¤
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 will this person’s age be 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

11860145

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

§,w"U¤
Person 7
8.

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.

9.

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 S4,
continue with the next person on the Continuation
Questionnaire (D-CQ-TL), and update number of
continuation questionnaires on page 1.

15

11860152

§,w"]¤

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 (S2=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

11860160

Day