Special Census Program

SC-IS (3-29-2023)

OMB No. 0607-0368

DC

INFORMATION SHEET
RELATIONSHIP

We need to count people where they
live and sleep most of the time.

Do include:

• College students who live
away from this address
most of the year.

• Babies and children living
here, including foster
children.

• Armed Forces personnel
who live away.

• Roommates.

• People in jail, prison,
detention facility, etc. on
the Special Census Day.

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• Boarders.

• People staying here on
the Special Census Day
who have no permanent
place to live.

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• People in a nursing home,
mental hospital, etc. on
the Special Census Day.

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Do NOT include:

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WHO TO COUNT

How is this person related to Person 1? Mark J
K
I ONE box.
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

Adopted son or daughter

Roommate or housemate

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

OMB No. 0607-0368

DC

INFORMATION SHEET
RACE

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HISPANIC ORIGIN
Is this person of Hispanic, Latino, or Spanish origin?

What is this person’s race?
Mark J
K
I one or more boxes AND print origins.

No, not of Hispanic, Latino, or Spanish origin

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

Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

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

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

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

Some other race – Print race or origin.

SC-IS (3-29-2023)

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

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