D-Q-MV Maritime Vessel Questionnaire

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

Coast Guard Number

7.

Besides this vessel, what is the full address of a place
where you usually live or stay when off duty?

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Vessel Call Sign

3.

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

What is the Vessel Call Sign and Coast Guard Number?

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

I never stay at any other place when off duty. I only live on
this vessel.
Address Number (For example: 5007)

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2.

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

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

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)

City

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ZIP Code

➜ 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 is your age 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.

Age on April 1, 2020
years
FORM

D-Q-MV (01-16-2019) Draft 18

Print numbers in boxes.
Month
Day

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

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State

Chinese

Year of birth

Some other race – Print race or origin. C

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

11670023

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Maritime Vessel Questionnaire

Economics and Statistics Administration

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

This is your Maritime Vessel 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 Maritime Vessel Questionnaire, you help ensure an accurate count of
all populations in the 2020 Census.

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This Maritime Vessel Questionnaire is to be used to count people who were living or staying on U.S. flag
vessels on April 1, 2020. 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 on this maritime vessel. 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 Census Maritime Vessel 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.

FORM D-Q-MV (01-16-2019) Draft 18

GQ Control Number

A. PN

11670015

DC

UNITED STATES DEPARTMENT OF COMMERCE

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