D-Q-RA Enumerator Questionnaire Remote Alaska

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

TM

Enumerator Questionnaire

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

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).
Is this (address)? If respondent says no, ask, “Can you tell
me where to find (address)?” and then end interview.

C

Owned by you or someone in this household free and
clear, without a mortgage or loan?

Will you or anyone in this household live or stay here on
April 1, 2020?

No – Skip to S4.

S6.

Does someone usually live at this
[house/apartment/mobile home], or is this a vacation or
seasonal home where no one usually lives?

ft:

Rented?
Occupied without payment of rent?

N

o

Yes – I am here to complete a 2020 Census questionnaire
for this address. It should take about 10 minutes (hand
respondent a confidentiality notice). This notice explains that
your answers are confidential.

S3.

On April 1, 2020, will this [house/apartment/mobile home] be
Mark K
J ONE box.
I
Owned by you or someone in this household with a
mortgage or loan, including home equity loans?

Respondent confirmed address.

S2.

S5.

iti

S1.

ze

No

We need to count people where they live and sleep most
of the time. 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 will be living or staying in
this [house/apartment/mobile home] on April 1, 2020?
Number of people =

Usually lives here – Skip to S5.

S7.

On April 1, 2020, will this unit be

Will there be any additional people staying here on
April 1, 2020 that you did not include in the count in the
previous question? For example:
Mark K
J all that apply. Include any additional people on
I
the person pages.

Occupied by a different household? – Using a knowledgeable
respondent, complete this questionnaire for the people that will
be occupying the household on April 1, 2020.

D

S4.

ra

Vacation or seasonal home or held for occasional use – Skip
to “Respondent Information” on Page 8.

Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

Vacant? – Skip to “Respondent Information” on Page 8.

Relatives, such as adult children, cousins, or in-laws

Not a housing unit – Skip to “Respondent Information”
on Page 8.

Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
No additional people

FORM

D-Q-RA (02-05-2019) Draft 14

11790011

§,p!>¤
Person 1
1.

5.

Now I am going to ask you questions about each person
who will be living here. If someone will be living here who
will pay the rent or own this residence, I would like to start
by listing him or her as Person 1. If the owner or the person
who pays the rent will not live here, I can start by listing any
adult who will be living 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

Samoan

Asian Indian

Japanese

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

Some other race – Print race or origin. C

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

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

C

years

Native Hawaiian

Filipino

iti

3.

Vietnamese

ze

Chinese

➜ If more people were counted in Question S6 on the
front page, continue with Person 2 on the next page.

2

11790029

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Person 2
1.

7.

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)

At a seasonal or
second residence

No

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

ze

In a nursing home

Opposite-sex husband/wife/spouse

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

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

C

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

Some other race – Print race or origin. C

o

Is this person male or female? Mark K
J ONE box.
I
Female

N

Male

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

ft:

5.

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

For another reason

For a job or business

4.

ip

In a jail or prison

For college

ns
h

With a parent or other relative

For a military assignment

3.

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

Does this person usually live or stay somewhere else?
For example – Read examples to respondent.
Mark K
J all that apply.
I

iti

2.

Age on April 1, 2020

Year of birth

ra

years

D

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6. 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
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 3 on the next page.

3

11790037

§,p!N¤
Person 3
1.

7.

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)

At a seasonal or
second residence

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

For another reason

For a job or business

No

In a nursing home

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I

Vietnamese

ze

Chinese

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

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

iti

Opposite-sex husband/wife/spouse

Native Hawaiian

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

Some other race – Print race or origin. C

Is this person male or female? Mark K
J ONE box.
I
Female

N

Male

o

4.

ip

In a jail or prison

For college

ns
h

With a parent or other relative

For a military assignment

3.

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

Does this person usually live or stay somewhere else?
For example – Read examples to respondent.
Mark K
J all that apply.
I

C

2.

5. 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.
Year of birth

ra

years

Print numbers in boxes.
Month
Day

ft:

Age on April 1, 2020

D

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6. 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
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 4 on the next page.

4

11790045

§,p!U¤
Person 4
1.

7.

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)

At a seasonal or
second residence

No

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

ze

In a nursing home

Opposite-sex husband/wife/spouse

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

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

C

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

Some other race – Print race or origin. C

o

Is this person male or female? Mark K
J ONE box.
I
Female

N

Male

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

ft:

5.

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

For another reason

For a job or business

4.

ip

In a jail or prison

For college

ns
h

With a parent or other relative

For a military assignment

3.

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

Does this person usually live or stay somewhere else?
For example – Read examples to respondent.
Mark K
J all that apply.
I

iti

2.

Age on April 1, 2020

Year of birth

ra

years

D

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6. 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
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 5 on the next page.

5

11790052

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Person 5
1.

7.

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)

At a seasonal or
second residence

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

For another reason

For a job or business

No

In a nursing home

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I

Vietnamese

ze

Chinese

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

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

iti

Opposite-sex husband/wife/spouse

Native Hawaiian

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

Some other race – Print race or origin. C

Is this person male or female? Mark K
J ONE box.
I
Female

N

Male

o

4.

ip

In a jail or prison

For college

ns
h

With a parent or other relative

For a military assignment

3.

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

Does this person usually live or stay somewhere else?
For example – Read examples to respondent.
Mark K
J all that apply.
I

C

2.

5. 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.
Year of birth

ra

years

Print numbers in boxes.
Month
Day

ft:

Age on April 1, 2020

D

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6. 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
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 6 on the next page.

6

11790060

§,p!o¤
Person 6
1.

7.

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)

At a seasonal or
second residence

No

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark K
J ONE box.
I

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

ze

In a nursing home

Opposite-sex husband/wife/spouse

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

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

C

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

Some other race – Print race or origin. C

o

Is this person male or female? Mark K
J ONE box.
I
Female

N

Male

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

ft:

5.

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

For another reason

For a job or business

4.

ip

In a jail or prison

For college

ns
h

With a parent or other relative

For a military assignment

3.

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

Does this person usually live or stay somewhere else?
For example – Read examples to respondent.
Mark K
J all that apply.
I

iti

2.

Age on April 1, 2020

Year of birth

ra

years

D

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.
6. 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
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more than 6 people were counted in Question S6,
continue with the next person on the Continuation
Questionnaire (D-CQ-RA), and update number of
continuation questionnaires on page 1.

7

11790078

§,p!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: Will you
Live or stay in this [house/apartment/mobile home]
on April 1, 2020?

Address of proxy

ip

Move in to this [house/apartment/mobile home]
after April 1, 2020?

INTERVIEW SUMMARY

A.

B.

Unit Status on April 1, 2020
Occupied

ns
h

Not live or stay in this [house/apartment/mobile home]
(neighbor or other proxy)?

C.

If vacant, ask: Which category best
describes this vacant unit for
April 1, 2020?

Vacant – regular

For rent

Vacant – usual home elsewhere

01 – 99 = Total people
00 = Vacant

ze

Rented, not occupied

Number of people
listed on questionnaire(s) =

Uninhabitable/demolished/burned out

For sale only

Nonresidential

Sold, not occupied

Empty mobile home/trailer site

Language Code =

E.

Interview Outcome Code

For seasonal, recreational or
occasional use

UHE

REF

For migrant workers

MOV

CO

iti

Unable to Locate

D.

Duplicate – record Survivor ID below. C

C

Other vacant

JIC1

JIC2

MM

In-Person

DD

HH

/

MM

:

Outcome

Type

a.m.

N

Type

✗

o

RECORD OF CONTACT

In-Person

p.m.

MM
In-Person

DD

HH

MM

DD

HH

/

ra

In-Person

:

ft:

/

Telephone

MM

:

Telephone

D

OUTCOME CODES: RV = Left Record of Visit

HH

/

MM

p.m.

Telephone
Outcome

a.m.

:
DD

In-Person

p.m.

Telephone

RE = Refusal

HH

/

MM

Outcome
a.m.

:

p.m.
MM

a.m.

Outcome

p.m.
MM

In-Person

NC = No Contact

DD

Telephone
Outcome

a.m.

MM

MM

DD

/

CI = Conducted Interview

HH

MM

Outcome
a.m.

:

p.m.

OT = Other

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

Employee ID
CFS Area

Month

Day

Month

8

11790086

Day