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D-1(E)(SUPP) Enumerator-NRFU Supplemental
ICR 200910-0607-004 · OMB 0607-0919 · Object 14099401.
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Draft 4 7/24/2008 OMB No. 0607-0919-C: Approval Expires 12/31/2011 NOTES Form of Form(s) TRANSCRIBE UNIT ID FROM THE LABEL ON D-1(E) OR D-15 QUESTIONNAIRE REP Unit ID LCO State County Tract Block AA Map Spot CONTINUATION FORM FOR ENUMERATOR QUESTIONNAIRES D-1(E)SUPP - Tone prints in Pantone Process Cyan - 10%, 25%, 50% and 100% – D-1(E)SUPP - Base print in Black ink NOTES USCENSUSBUREAU §n#"¤ 770201 Form D-1(E)SUPP (7-24-2008) Draft 4 7/24/2008 Person No. First Name MI Last 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. 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 Is (Name) male or female? Male Female Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative 4. What was (Name’s) age on April 1, 2010? What is this person’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 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, Columbian, 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 No. 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 Unmarried partner Other nonrelative Age on April 1, 2010 DATE OF BIRTH Month Day 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 Unmarried partner Other nonrelative Age on April 1, 2010 DATE OF BIRTH Month Day Please look at List D and choose one or more races. For this census, Hispanic origins are not races. 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 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 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 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 Age on April 1, 2010 DATE OF BIRTH Other relative Roomer or boarder Housemate or roommate Unmarried partner Other nonrelative Month 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 No. 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 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? ➙ 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? ➙ 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? FORM D-1(E)SUPP (7-24-2008) 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 ➙ Some other race — What is that group? Person No. 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 ➙ Some other race — What is that group? Year of birth Person No. 6. Other Asian — What is that group? C Other Pacific Islander — What is that group? ➙ 7. Does (Name) sometimes live or stay somewhere else for any of these reasons? — 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 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 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 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 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 §n##¤ 770202 D-1(E)SUPP - Tone prints in Pantone Process Cyan - 10%, 25%, 50% and 100% Who else lived or stayed here on April 1, 2010? D-1(E)SUPP - Base print in Black ink 1.
| File Type | application/pdf |
| File Title | D-1(E)SUPP_2_1.g |
| File Modified | 2008-07-24 |
| File Created | 2008-07-24 |