Special Census Program

Draft 1 (6-14-2022)

This listing contains confidential information, including Title 13 and Personally Identifiable Information (PII), the release of which is prohibited by the Privacy Act of 1974

OMB No. xxx-xxxx
U.S. DEPARTMENT OF COMMERCE

U.S. CENSUS BUREAU

SCID:

State:

AA:

County:

Line
No.

Do Not
Interview

(2)

(3)

Action
Code

(4)

Print Date/Time
Page

Date Listed
(month/day)

Address
Status

Address
Type

Block No.

Map Spot
No.

of

Location Address or Physical Location Description
Address No.

Street Name and Type

Apt/Unit No.

(5)

(12)

Date SC-Q Completed
(month/day)

Physical Location Description

(15)

(13)

Zip Code

(7)

(6)

(8)

(9)

(10)

(11)

FS
Use
Only

GQ or TL Name/Facility Name
(14)

(16)

(17)

T

(1)

Barcode
ID

ADDRESS LIST PAGE
Special Census

AF

1

2

R

3

D

4

5

6

7

Action Codes – For entry in column (4):
V – Verified
C – Correction
U – Uninhabitable
FORM

SC-920

(6-14-2022)

N – Nonresidential
E – Empty Mobile Home/Trailer Site
DCL – Unable to Locate

CW – Cannot Work
D2 – Duplicate

Action Codes – Do Not Interview:
Z – Group Quarters (GQ)
T – Transitory Location (TL)
X – Questionnaire Previously Completed

Address Type:
S – Single Unit
M – Multi Unit

T – Trailer/Mobile Home
O – Other

Address Status:
HU – Housing Unit
GQ – Group Quarters
TL – Transitory Location

Draft 3 (8-12-2022)

FORM

of

Page

SC-921 (8-12-2022)

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

This listing contains confidential information, including Title 13 and Personally Identifiable Information (PII), the release of which is prohibited by the Privacy Act of 1974
U.S. DEPARTMENT OF COMMERCE

U.S. CENSUS BUREAU

ADD PAGE
Special Census
Case ID
(from Form SC-Q)

Date Listed

(2)

(4)

(3)

Date SC-Q
Completed
(5)

(6)

(7)

HU – Housing Unit
GQ – Group Quarters
TL – Transitory Location
GQ or TL Name/Facility Name
(12)

Street or Road Name

Apt/Unit No.

(8)

(10)

(13)

Physical Location Description

ZIP Code

GQ or TL Contact Telephone Number

(9)

(11)

(14)

AF
T

(1)

Address
No.

Address Status:

AA:

Location Address or Physical Location Description

R

Block No.

Address
Status

D

Line
No.

SCID:

GQ or TL Contact Name

FS
Use
Only

(15)