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D-1(E) Enumerator-NRFU
ICR 200910-0607-004 · OMB 0607-0919 · Object 14099101.
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Draft 5 8/27/2008 OMB No. 0607-0919-C: Approval Expires 12/31/2011 RESPONDENT INFORMATION U.S. CENSUS BUREAU R1. We do not want to miss any people who might have been staying here on April 1. Were there any additional people that you didn’t mention, for example: R2. (Ask or verify) What is your name? First Name No No No No No Yes No MI Area Code – Day Address of proxy R3. Last Name A. Unit Status on April 1, 2010 Occupied Vacant - regular Vacant - usual home elsewhere Demolished/burned out/cannot locate Nonresidential Empty mobile home/trailer site Uninhabitable (open to elements, condemned, under construction) Duplicate – record ID of Dup. C Do you or does someone in this household own this (house/apartment/mobile home) with a mortgage or loan, including home equity loans; own it free and clear; rent it; or occupy it without having to pay rent? B. Street name or rural route address For rent Rented, not occupied For sale only Sold, not occupied For seasonal, recreational or occasional use For migrant workers Other vacant Number of people listed on form(s) = 1 - 49 = Total people 00 = Vacant 98 = Delete 99 = POP unknown Tract Block AA Map Spot Are there any continuation forms for this address? Yes ➙ UHE D. What language was the majority of the interview conducted in? E. MOV F. CO I. Other – Specify language number from flashcard ➙ PI G. REP REF H. VDC J. Mo L. Enumerator’s signature Employee ID Mo Day S1. JIC2 M. : a.m. p.m. : a.m. p.m. Outcome Time Outcome Type Mo Personal Telephone Mo Personal Telephone Mo Personal Telephone Hello, I’m (Name) from the U.S. Census Bureau. (Show ID). Is this (Address)? S4. Yes - Continue with question S2. No - Ask: Can you tell me where to find (Address)? END INTERVIEW. Crew Leader’s initials S2. CLD number Month Day : a.m. p.m. Time Personal Telephone Day I’m here to complete a Census questionnaire for this address. It should take about 10 minutes. (Hand respondent Information Sheet.) The first part explains that your answers are confidential. I’ll refer to the other parts later. Did you or anyone in this household live or stay here on April 1, 2010? Yes - Continue with question S3. No - Skip to question S4. S3. Month Day Outcome Time Personal Telephone CERTIFICATION I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge. Day Day Day Day Outcome Time : a.m. p.m. : a.m. p.m. : a.m. p.m. Outcome Time Time Outcome OUTCOME CODES: NV = Left Notice of Visit NC = No Contact RE = Refusal CI = Conducted Interview OT = Other K. JIC1 ZIP Code Go to respondent Information on back page. Number of forms No Type I J K Personal Spanish NOTES County RECORD OF CONTACT English State State ➤ APPLY LABEL HERE Mo Apartment number City C. If vacant, ask: Which category best describes this vacant unit as of April 1, 2010? (Read categories.) If there is not an address label affixed, or if the address label includes only a location description, ask – What is the address of this unit? House number LCO – INTERVIEW SUMMARY Own with a mortgage or loan (including home equity loans) Own free and clear (without a mortgage or loan) Rent Occupy without payment of rent H3. Either Respondent Type – Last Name Do not list any people recorded for this question on the inside pages or on a continuation form. H2. Evening Household member – Lived here on April 1, 2010 Household member – Moved in after April 1, 2010 Neighbor or other proxy Anyone else? First Name – Unit ID Last Name If yes to any category, ask: What is that person’s name? First Name Number Does someone usually live at this (house/apartment/mobile home), or is this a vacation or seasonal home? Usually lives here - Skip to question S5. Vacation or seasonal home or held for occasional use – Skip to "Respondent Information" on back page. USCENSUSBUREAU (Only ask if no household member lived here on April 1.) On April 1, was this unit vacant, or occupied by a different household? Vacant - Skip to "Respondent Information" on back page. Occupied by a different household - Using a knowledgeable respondent, complete this questionnaire for the Census Day household. Not a housing unit – Skip to "Respondent Information" on back page. S5. We need to count people where they live and sleep most of the time. Please look at list A. It contains examples of people who should and should not be counted at this place. Based on these examples, how many people were living or staying in this (house/apartment/mobile home) on April 1? = Number of people §k""¤ 740101 Form D-1(E) (8-27-2008) D-1(E) - Tone prints in Pantone Process Cyan - 10%, 15%, 25% and 50% Yes Yes Yes Yes Yes ENUMERATOR QUESTIONNAIRE What is your phone number and best time to call? D-1(E) - Base print in Black ink Babies? Foster children? Any other relatives? Roommates? Any other nonrelatives? How about anyone else staying here on April 1 who had no permanent place to live? Economics and Statistics Administration ➤ H1. U.S. DEPARTMENT OF COMMERCE Draft 5 8/27/2008 Person 1 First Name 2. Please look at list B on the Information Sheet. How is (Name) related to (Read name of Person 1)? 3. Mark I J K ONE box. Mark I J K ONE box. I J K Person 1 Is (Name) male or female? Male Female MI 4. What was (Name’s) age on April 1, 2010? What is (Name’s) date of birth? Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes. Age on April 1, 2010 DATE OF BIRTH Month Last Name Day 5. Please look at List C. Is (Name) of Hispanic, Latino, or Spanish origin? Read if necessary: Examples of another Hispanic, Latino, or Spanish origin include Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – What is that origin? C Year of birth Person 2 First Name MI Last Name Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Male Female Other relative Roomer or boarder Housemate or roommate Age on April 1, 2010 DATE OF BIRTH Month Day Unmarried partner Other nonrelative First Name MI Last Name Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Male Female Other relative Roomer or boarder Housemate or roommate Age on April 1, 2010 DATE OF BIRTH Month Day Unmarried partner Other nonrelative Please look at List D and choose one or more races. For this census, Hispanic origin is not a race. What is (Name’s) race? Read if necessary: Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. Examples of other Pacific Islander groups include Fijian, Tongan, and so on. White Black, African American, or Negro American What is the name of the enrolled or principal tribe? C Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Some other race — What is that group? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – What is that origin? C Year of birth Person 3 6. Year of birth First Name MI Last Name Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Male Female Other relative Roomer or boarder Housemate or roommate Age on April 1, 2010 DATE OF BIRTH Month Unmarried partner Other nonrelative No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – What is that origin? C Day Year of birth Person 5 First Name Last Name MI Husband or wife Biological son or daughter Adopted son or daughter Stepson or stepdaughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative Male Female Age on April 1, 2010 DATE OF BIRTH Month Day Year of birth Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan FORM D-1(E) (8-27-2008) Other Asian — What is that group? C Other Pacific Islander — What is that group? ➙ Black, African American, or Negro American What is the name of the enrolled or principal tribe? C Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Asian — What is that group? C Other Pacific Islander — What is that group? ➙ Mark I J K all reasons that apply. In college housing In the military At a seasonal or second residence For child custody In jail or prison In a nursing home For another reason In college housing In the military At a seasonal or second residence For child custody In jail or prison In a nursing home For another reason In college housing In the military At a seasonal or second residence For child custody In jail or prison In a nursing home For another reason No White Black, African American, or Negro American What is the name of the enrolled or principal tribe? C Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Asian — What is that group? C Other Pacific Islander — What is that group? ➙ In college housing In the military At a seasonal or second residence For child custody In jail or prison In a nursing home For another reason No White Black, African American, or Negro American What is the name of the enrolled or principal tribe? C Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan ➙ Read response categories. No White Some other race — What is that group? Does (Name) sometimes live or stay somewhere else for any of these reasons? – No American What is the name of the enrolled or principal tribe? C Indian or Alaska Native Some other race — What is that group? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – What is that origin? C ➙ Black, African American, or Negro Some other race — What is that group? Person 4 Other Pacific Islander — What is that group? White Some other race — What is that group? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin – What is that origin? C Other Asian — What is that group? C 7. D-1(E) - Tone prints in Pantone Process Cyan - 10%, 25% and 50% Let’s make a list of all those people. Please start with the name of an owner or renter who was living here on April 1. Otherwise, start with any adult living here. Other Asian — What is that group? C Other Pacific Islander — What is that group? In college housing In the military At a seasonal or second residence For child custody In jail or prison In a nursing home For another reason No §k"#¤ 740102 D-1(E) - Base print in Black ink 1.
| File Type | application/pdf |
| File Title | D-1(E)_1_1.g |
| File Modified | 2008-08-27 |
| File Created | 2008-08-27 |