SC-Q-GE GQ Individual Census Questionnaire (English)

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

OMB No. xxxx-xxxx

Start here

Use a blue or black pen.

1. What is your name? Print name below.
First Name

MI

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

6.

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

Last Name(s)

Yes, Puerto Rican
Yes, Cuban

2.

Do you live or stay here most of the time?
Yes

3.

No

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

Besides here, what is the full address of a place
where you sometimes live or stay?
I never stay at any other place. I only live here.

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

Address Number (For example: 5007)

Street Name (For example: N Maple Ave)

T

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

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

R
AF

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

D

Rural Route Address (if there is no street address)

City

State

ZIP Code

➜ NOTE: Please provide a location description below if there is no

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

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

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

address or if this is a facility.

Some other race – Print race or origin. C

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

Female

5. What was your age on (Special Census Day), 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 (Special Census Day) Month
Day
Year of birth
years
FORM

SC-Q-GE

(10-17-2022) D7

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

23033012

§8$?-¤

Special Census
Individual Census Questionnaire

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

DC

OMB No. xxxx-xxxx

UNITED STATES DEPARTMENT OF COMMERCE
U.S. Census Bureau
Office of the Director
Washington, DC 20233-0001

This is your Individual Census Questionnaire for the Special Census. The U.S. Census Bureau is conducting this
Special Census to provide your local government with current population and housing counts for this area. Your
participation in the Special Census is extremely important. Although the individual responses are voluntary, the
information the Special Census receives from you ensures the completeness and accuracy of the results.
This Individual Census Questionnaire is to be used to count people who were living, staying or receiving services in
group quarters on the Special Census Day. 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.
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 Special Census under the authority of Title 13, U.S. Code, Section 196. 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.

R
AF

T

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.

D

Disclosure of the information provided to us is permitted under the Privacy Act of 1974 (Title 5, U.S. Code, Section
552a) and may be shared with other Census Bureau staff for the work-related purposes. 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. Click on "System of Records Notices (SORN)" or visit
. This page also includes information about the
collection, storage, disclosure and published routine uses of Privacy Act System of Records Notice
COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame) (name change from
COMMERCE/CENSUS-3, Special Censuses, Surveys, and Other Studies, pending publication in the Federal
Register).

Thank you for completing your Special Census Questionnaire.
FOR OFFICIAL USE ONLY

The Census Bureau estimates that completing the
questionnaire will take 10 minutes on average. Send any
comments concerning this collection by email to
and 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 Special Census.

GQ Case ID
–

A. PN

B. Answered By:

C. QC:

FORM SC-Q-GE (10-17-2022)

–

Rework

Respondent

Group Quarters
Administrator

Observation
(TNSOLs only)

Other

23033020

§8$?5¤

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