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OMB No. XXXX-XXXX
Special Census
Reinterview Questionnaire
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU
REINTERVIEW
Ask questions 1-7 during reinterview.
1. Hello, I’m (name) from the U.S. Census Bureau (show ID).
May I speak to (original respondent name)?
Yes
No – Ask when the original respondent will be available. If
unable to interview the original respondent, interview a
knowledgeable proxy.
2. I’m contacting you to check on the quality of our Special
Census interview. It should take less than 10 minutes.
Were you recently interviewed for the Special Census
about (address)?
ORIGINAL RESPONDENT INFORMATION
Yes
Use original questionnaire to complete OR1 - OR4.
OR1.
Original Respondent’s Name
No – Conduct a full interview using the SC-Q questionnaire.
MI
Don’t know – Conduct a full interview using the SC-Q
questionnaire.
T
First Name
3.
Did anyone live or stay at (address) on (Special Census
Day)?
AF
Last Name(s)
Yes – SKIP to question 5.
Original Respondent Telephone Number
–
OR3.
–
Original Respondent Type
No
4.
On (Special Census Day), was this unit
R
OR2.
Vacant? – End reinterview.
D
Lived or stayed in this [house/apartment/mobile home] on
(Special Census Day)
Moved into this [house/apartment/mobile home] after
(Special Census Day)
Did not live or stay in this [house/apartment/mobile home]
(neighbor or other proxy)
OR4.
Address of Neighbor or Proxy
Not a housing unit – End reinterview.
5.
We need to count people where they live and sleep most
of the time. (Hand respondent an Information Sheet.) Please
read the WHO TO COUNT section on the Information
Sheet. Based on these instructions, how many people
were living or staying in this [house/apartment/mobile
home] on (Special Census Day)?
Number of people =
6. Were there any additional people staying here on
(Special Census Day) that you did not include in the count
in the previous question? For example:
Mark I
K all that apply. Include any additional people on
J
the next page.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children
Relatives, such as adult children, cousins, or in-laws
Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
No additional people
FORM
SC-RQ
23113012
(10-07-2022) Notional Draft D4
§8,?5¤
7.
I need to make a list of the people who lived or stayed at (address) on (Special Census Day). Please tell me your name first
and then the names of everyone else who was living or staying here on (Special Census Day).
First Name
MI
Last Name(s)
1.
2.
3.
4.
5.
6.
7.
8.
10.
T
9.
REINTERVIEW RECORD OF CONTACT
Month
In-Person
Day
Hour
Minute
/
:
Telephone
Month
In-Person
Day
Hour
/
Type
In-Person
p.m.
Telephone
Outcome
In-Person
Hour
/
:
Outcome
OUTCOME CODES: NV = Left Notice of Visit
In-Person
p.m.
Telephone
NC = No Contact
/
Minute
RE = Refusal
Outcome
a.m.
:
p.m.
Day
Hour
/
Minute
Outcome
a.m.
:
p.m.
Month
a.m.
D
Telephone
Minute
Hour
Telephone
R
Day
Day
Month
p.m.
Month
Month
a.m.
a.m.
:
Telephone
In-Person
Minute
Outcome
AF
Type
Day
Hour
/
CI = Conducted Interview
Minute
Outcome
a.m.
:
p.m.
OT = Other
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
Field Supervisor
Initials
FSA Number
Month
Year
Day
REINTERVIEW STATUS
If you select "Defer to Supervisor" write a detailed reason for deferring this RI in the
NOTES section of this form.
Clerk Office Review - Initial ᇉ
Pass
Defer to Supervisor
Supervisor Review - Final ᇉ
Pass
Soft Fail
Month
Hard Fail
Notes:
FORM SC-RQ (09-26-2022)
Clerk Initials
23113020
Non-interview
Day
Year
| File Type | application/pdf |
| File Title | SC_RQ_23_p01.pdf |
| Author | OneFormUser |
| File Modified | 2022-10-07 |
| File Created | 2022-09-26 |