SC-116 Group Quarters Control Record

FORM

SC-116 (1-19-2023)

OMB No. 0607-0368

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

GROUP QUARTERS CONTROL RECORD
Special Census
THIS LISTING CONTAINS INFORMATION, THE RELEASE OF WHICH IS PROHIBITED BY TITLE 13, U.S.C.

G.

H. Zip Code: C

State: C

/
I.

County: C

J.

K.

AA: C

L. Tract: C

M.

Block: C

N.

O.

Location description: C

P.

Building name: C

Q.

Building number: C

GQ Type Code: C

A. Case ID:C

B. SCID/GU name: C

C. GQ name:

C

D. Facility name:

E.

F.

Map Spot: C

C

Street address: C

City: C

Section A – Group Quarters Facility Contact Information
Confirm, update or collect the GQ Contact information. (Complete Items 1 to 3)
Question 1, SC-351

Question 2, SC-351

1. Contact name:

2. Contact title:
Cell

3. Telephone number(s), including
area code and extension:

(

)

–

Ext.

Home/Other

(

–

)

Section B – Group Quarters Information
Question 3, SC-351

Question 4, SC-351

8. Is GQ Type
Code correct?

4. GQ name:

1
2

YES
NO ➜

New GQ
Type code:

(Only MINOR spelling corrections are allowed)
Question 5, SC-351

5. Street name:

9. Max Pop:
Question 6, SC-351

6. Facility name:
7. Potential duplicate:

1

YES

2

NO

GQ operating on
10. Special Census date:

Continued on next page

1

YES

2

NO

3

Don’t know

Section B – Group Quarters Information – Continued
Question 7, SC-351

Question 8, SC-351

➜ 12. 1

11. Expected Pop:

Male

Female

2

3

Both
Question 9b, SC-351

Question 9a, SC-351

13. Records with requested information:

1

YES

2

NO

1

YES

2

NO

14. Type of Records:

1

Paper

2

Computer

Both

3

Question 9c, SC-351

15. Records available to Census worker:
Question 10a and 10b, SC-351

16. Enumeration method:

Administrative Records

1

In Person Interview

2

Drop Off/Pick Up

3

Question 11, SC-351

17. Approximate number of persons at TNSOL:
Question 12, SC-351

18. Other languages:

1

NO

YES (List Languages)

2

➜ ①

②

Question 13, SC-351

19. Specific instructions:
Question 14, Questions
15b and 15e, SC-351

Month/Day/Year

/

20. Enumeration appointment:
Question 15a, SC-351

Question 15b, SC-351

22. Client arrival time:

Time

2

1

:

2

am
pm

2

am
pm
Time

am
pm

1

:

1

:

/

Time

21a. Shelter opening time:

Time

Question 15c, SC-351

2

Time

23. Latest time clients can enter shelter:

Question 15d, SC-351

am
pm

1

:

21b. Shelter closing time:

am
pm

1

:

2

Question 16a, SC-351

24. Procedures when clients enter
the shelter C

25a. Enumeration contact same as facility contact: 1

NO

YES 2

C

Contact name:
Contact title:
Contact phone No.
Question 16b, SC-351

(

–

)

Question 17, SC-351

25b. Staff helping with enumeration?

1

YES 2

26. GQ Contact responsible for additional locations?

NO

1
2

YES
NO

27. Status code for the GQAC interview (Select one):
1

Complete

6

Cannot Locate

11

Closed on Special Census Day

2

Housing Unit

7

Demolished/Burned Out

12

3

Transitory Location

8

Duplicate Survivor ID #

Uninhabitable (Open to the Elements/
Condemned/Under Construction)

4

Out of Enumeration Area

9

Refusal

13

Dangerous Address

5

Nonresidential

Military or Maritime Vessel

14

Unresolved (Cannot reach by phone)

10

Notes

Page 2

Continued on next page

FORM SC-116 (1-19-2023)

Section C – Enumeration Information
Month/Day/Year

Print Field Representative’s Name

28. Assigned to:

/

29. Date assigned:

/

Month/Day/Year

/

30. Date Enumeration completed:

/

31. Total ICQs:

(Total Pop)

Certification
Field Representative – I certify that the entries made on this form are true and correct to the best of my knowledge.
32. Field Representative signature:

33. Date signed:

For Supervisory Use Only
34. Zero Pop. reason (Mark (X) only ONE):
1

Refusal

6

Nonresidential

2

Duplicate Survivor ID #

7

Occupied As of Special Census Day but no one there as of Enumeration Date

3

Military or Maritime Vessel

8

Dangerous Address

4

Out of Enumeration Area

9

Demolished/Burned Out

5

Cannot Locate

10

Uninhabitable (Open to the Elements/Condemned/Under Construction)

For SCO Use Only
35. Our records show our Census Field Representative visited your facility on
(transcribe date from Item 20 above) to count your residents/clients. Is this correct?
1

YES (Go to item 36.)

NO – Thank the respondent
and end the interview. Record response hereC

2

3

I don’t know (Go to item 36.)

36. What is the approximate number of residents/clients you think were counted as a result of that visit? This
number might be different than the maximum number of persons you could have at your facility.
Number of residents/clients

I don’t know

37. SCO Clerk signature:
Month/Day/Year

39. Date signed:

38. Clerk ID:

For Supervisor Use Only – RI Result
1

Pass

2

Soft Fail

3

Hard Fail

4

Non-Interview

Notes

FORM SC-116 (1-19-2023)

Page 3