SC-Q-TL Transitory Unit Questionnaire (English)

§8#?.¤

OMB No. XXXX-XXXX

Special Census
Transitory Unit Questionnaire

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

FOR NPC
USE ONLY

SCID

State

AA
–

TL Case ID:

County

TL Tract

TL Block

–

UNIT ADDRESS
TU Tract

TU Block

Address Number (example: 5007)

Street or Road Name (example: N Maple Ave)

ZIP Code

T

Write the full address of
the transitory unit and/or
a location description ➜

Unit/Site Number (column A)

Rural Route

AF

Copy transitory unit
information from the
Transitory Location
Listing Sheet (SC-693.2) ➜

Location Description

S1.

D

R

Rural Route or Location Description (if applicable)

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]?” and then end interview.

S3.

Is this [RV/boat/room/unit]
Mark K
J
I ONE box.
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?

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

Rented?

S2.

I am here to complete a Special 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?

Occupied without payment of rent?

S4.

Yes– End interview.

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] who have no other
place where they usually live?

No
Number of people =

FORM

SC-Q-TL

23023013

(10-05-2022) Notional Draft

§8#?6¤
Person 1
1. Now I am going to ask you questions about each person

5. Please read the RACE section on the Information Sheet.
What is Person 1’s race?
Mark I
K one or more boxes AND print origins.
J

who is currently living or staying in this [RV/boat/room/unit]
and has no other place where they usually live. If one of
those people pays the rent or owns this
[RV/boat/room/unit], I would like to start by listing him or
her as Person 1. If not, I can start by listing any adult.

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

Last Name(s)
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

2. Is Person 1 male or female? Mark I
K ONE box.
J
Male

Female

3. What was Person 1’s age on (Special Census Day)? What is

Filipino

Korean

Samoan

Japanese

Chamorro

Asian Indian

Print numbers in boxes.
Month
Day
Year of birth

years

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

R

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

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

Some other race – Print race or origin. C

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is Person 1 of Hispanic, Latino, or Spanish origin?

D

4.

Native Hawaiian

AF

Age on (Special Census Day)

Vietnamese

T

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.

Chinese

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

2

23023021

§8#?H¤
Person 2
1. What is Person 2’s name?

6.

Print name below and verify the spelling.
First Name

MI

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

Last Name(s)

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 I
K ONE box.
J
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

Chinese

Vietnamese

Native Hawaiian

Adopted son or daughter

Roommate or housemate

Filipino

Korean

Samoan

Stepson or stepdaughter

Foster child

Japanese

Chamorro

Brother or sister

Other nonrelative

T

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

Asian Indian

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

AF

2.

Please read the RACE section on the Information Sheet.
What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

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

Female

4. What was this person’s age on (Special Census Day)? What

R

Some other race – Print race or origin. C

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

D

Age on (Special Census Day)
years

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

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

5.

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

3

23023039

§8#?P¤
Person 3
1. What is Person 3’s name?

6.

Print name below and verify the spelling.
First Name

MI

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

Last Name(s)

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 I
K ONE box.
J
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

Chinese

Vietnamese

Native Hawaiian

Adopted son or daughter

Roommate or housemate

Filipino

Korean

Samoan

Stepson or stepdaughter

Foster child

Japanese

Chamorro

Brother or sister

Other nonrelative

T

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

Asian Indian

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

AF

2.

Please read the RACE section on the Information Sheet.
What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

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

Female

R

4. What was this person’s age on (Special Census Day)? 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.

years

Some other race – Print race or origin. C

Print numbers in boxes.
Month
Day
Year of birth

D

Age on (Special Census Day)

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

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

5.

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

4

23023047

§8#?W¤
Person 4
1. What is Person 4’s name?

6.

Print name below and verify the spelling.
First Name

MI

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

Last Name(s)

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 I
K ONE box.
J
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

Chinese

Vietnamese

Native Hawaiian

Adopted son or daughter

Roommate or housemate

Filipino

Korean

Samoan

Stepson or stepdaughter

Foster child

Japanese

Chamorro

Brother or sister

Other nonrelative

T

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

Asian Indian

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

AF

2.

Please read the RACE section on the Information Sheet.
What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

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

Female

4. What was this person’s age on (Special Census Day)? What

R

Some other race – Print race or origin. C

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

D

Age on (Special Census Day)
years

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

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

5.

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

5

23023054

§8#?_¤
Person 5
1. What is Person 5’s name?

6.

Print name below and verify the spelling.
First Name

MI

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

Last Name(s)

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 I
K ONE box.
J
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

Chinese

Vietnamese

Native Hawaiian

Adopted son or daughter

Roommate or housemate

Filipino

Korean

Samoan

Stepson or stepdaughter

Foster child

Japanese

Chamorro

Brother or sister

Other nonrelative

T

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

Asian Indian

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

AF

2.

Please read the RACE section on the Information Sheet.
What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

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

Female

R

4. What was this person’s age on (Special Census Day)? 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.

years

Some other race – Print race or origin. C

Print numbers in boxes.
Month
Day
Year of birth

D

Age on (Special Census Day)

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

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

5.

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

6

23023062

§8#?g¤
Person 6
1. What is Person 6’s name?

6.

Print name below and verify the spelling.
First Name

MI

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

Last Name(s)

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 I
K ONE box.
J
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

Chinese

Vietnamese

Native Hawaiian

Adopted son or daughter

Roommate or housemate

Filipino

Korean

Samoan

Stepson or stepdaughter

Foster child

Japanese

Chamorro

Brother or sister

Other nonrelative

T

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

Asian Indian

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

AF

2.

Please read the RACE section on the Information Sheet.
What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

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

Female

4. What was this person’s age on (Special Census Day)? What

R

Some other race – Print race or origin. C

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

D

Age on (Special Census Day)
years

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

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

5.

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 S4,
continue with the next person on the Continuation
Questionnaire (SC-CQ-TL), and update number of
continuation questionnaires on page 8.

7

23023070

§8#?y¤

OMB No. XXXX-XXXX

RESPONDENT INFORMATION

R1. What is your name? Print name below and verify the spelling. R2. What is your telephone number? We will only contact
First Name

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]?
Not live or stay in this [RV/boat/room/unit]
(neighbor or other proxy)?

INTERVIEW SUMMARY

C. Are there any continuation questionnaires for this address?

A. Language Code =

Yes ➜ Number of continuation questionnaires =

B. Number of people listed on questionnaire(s) =
01 – 99 = Total people

No

JIC2

T

JIC1

Type

Month

✗ In-Person

Day

/

Hour

Minute

:

AF

RECORD OF CONTACT
Outcome

Type

a.m.

✗ In-Person

Month

Day

Hour

/

Minute
a.m.

:

p.m.

NC = No Contact

RE = Refusal

CI = Conducted Interview

p.m.

OT = Other

R

OUTCOME CODES: NV = Left Notice of Visit

Outcome

CONFIRM TRANSITORY LOCATION NAME

D

Copy TL Name from the Transitory Location Listing Sheet (SC-693.2)

CERTIFICATION
I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.

Field Representative’s Signature

Month

Day

Employee ID

Year

8

23023088

Field Supervisor
Initials

FSA Number

Month

Year

Day