Address Listing121922

FORM SC-940 (11-18-2022)

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

This form 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

ADDRESS REGISTER COVER PAGE
Special Census

SCID:
AA:

1. ASSIGNMENT INFORMATION

Date (month/day)
Name

Employee
ID

Telephone
Number

(1)

(2)

(3)

(4)

Assigned
To

Accepted
From

(a) FS

Certification statement – I certify that
the information is true to the best of my
knowledge and the work completed
according to Census procedures.
Signature – The FR/Reassigned FR
and DQC FS must sign when the
assignment is completed.

(b) FR
(c) Reassigned
FR
(d) DQC FS
2. DAILY PROGRESS RECORD

(a) Date (month/day)
Number of
Questionnaires
Completed

(b) Today
(c) To Date

(d) Callbacks Outstanding
3. Remarks

FS Certification statement – I certify that I have reviewed the Address Register and all
accompanying documents and that the work has been completed satisfactorily.
Signature – FS must sign when the Address Register is accepted from the FR/Reassigned FR.

4. OFFICE USE ONLY

Date of Office
Review

Initials

The contents of this Address
Register are confidential by law
(Title 13, U.S. Code). It may be
seen only by sworn persons with
a need to know and used solely
for statistical purposes.

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)

Draft 4 (11-3-2022)

FORM

SC-901 (11-3-2022)

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

SCID:

U.S. CENSUS BUREAU

NOTES PAGE
Special Census
Line
No.

Notes

(1)

(2)

AA:

NOTES PAGE – (Continued)
Special Census
Line
No.

Notes

(1)

(2)

FORM SC-901 (11-3-2022)