Download:
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pdf§,p!,¤
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
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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
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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
§,p!]¤
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
| File Type | application/pdf |
| File Modified | 2019-02-08 |
| File Created | 2019-01-23 |