DX-15 Enumeration at Transitory Locations

RECORD OF CONTACT
Day

Month

Type

Time

US. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Outcome
a.m.
p.m.

Personal

RESPONDENT INFORMATION
LCO

MI

State

County

Last Name

2. Please look at List A. How is (Name) related to (Person 1’s Name)? Mark I
J
K ONE box.

2. Is (Name) male or female? Mark I
J
K ONE box.
Male

Last Name

Female

Unit ID

3a. What is (Name’s) date of birth? Print numbers in boxes.
Month

Address if proxy

(RV/boat/room/unit) who have no other place they usually live and sleep. This should take
about 10 minutes. (Hand respondent the Information Sheet, DX-1(F).) This Privacy Notice
explains that your answers are kept confidential. I’ll be referring to this Information Sheet
while we fill out the questionnaire.

S2. Including yourself, how many people are living or staying in this (RV/boat/room/unit)

and the best time to call?

3b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less
Age

HOUSING

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

H1. What is the mailing address of this unit?

Household Member – Lives Here
Neighbor
Landlord
Other Proxy

House No.

Street name, Rural Route and box, or PO box

Year

than 1 year old.
Age

5. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Yes, another Hispanic, Latino, or
Spanish origin — What is that group? C

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

Yes, another Hispanic, Latino, or
Spanish origin — What is that group? C

5. Please look at List C and choose one or more races. For this census, Hispanic origins
are not races. Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

INTERVIEW SUMMARY
Apt. No. or Location

POP
01–20 = Total persons

State

City

I certify that the entries I have made on this questionnaire are true and
correct to the best of my knowledge.
Month

Day

Crew Leader’s initials

CLD number

ZIP Code

Month

mortgage or loan, including home equity loans; own it free and clear; rent it; or
occupy it without having to pay rent?

Asian Indian
Japanese

Own with a mortgage or loan
Own free and clear
Rent
Occupy without payment of rent

Day

Chinese
Korean

Filipino
Vietnamese

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Chinese
Filipino
Asian Indian
Korean
Vietnamese
Other Asian — What is that group? C
Japanese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander — What is that group? C

Some other race — What is this group? C

Some other race — What is this group? C

JIC2

➜
Form DX-15 (5-1-2007)

USCENSUSBUREAU
Location of PID barcode

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, for example, Fijian, Tongan, and so on?
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander — What is that group? C

FOR OFFICIAL USE ONLY
JIC1

are not races. Is (Name) White; Black, African American, or Negro; American Indian or
Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on?

NOTES
Employee ID

6. Please look at List C and choose one or more races. For this census, Hispanic origins

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

H2. Do you or does someone in this household own this (RV/boat/room/unit) with a

CERTIFICATION

Enumerator’s signature

Day

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Either

R3. Respondent —

Month

4. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?

Number of people =
Evening

Day

Female

than 1 year old.

who have no other place they usually live?
–

–

1 = Occupied

3.

Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

4a. What is (Name’s) date of birth? Print numbers in boxes.

Number

A. Status of unit:

Year

Husband or wife
Father or mother
Biological son or daughter
Grandchild
Adopted son or daughter
Parent-in-law
Stepson or stepdaughter
Son-in-law or daughter-in-law
Brother or sister
Other relative
Is (Name) male or female? Mark I
J
K ONE box.
Male

S1. I will complete a census questionnaire for all the people staying at this

Area Code

Day

INTRODUCTION

R2. In case we need to contact you, what is your telephone number

MI

MI

First Name
Last Name

Block

Map Spot

AA

1. What is the name of another person staying here who has no other place he/she usually lives?
First Name

ADDRESS INFORMATION

R1. Enter Respondent’s name
First Name

owner or renter of this (RV/boat/room/unit) lives here, please give me that person’s name
first. If an owner or renter does not live here, start with the name of any adult living here.

2008 Dress Rehearsal
Transitory Location Questionnaire

OUTCOME CODE: CI=Conducted Interview

Person 2

1. I have a few questions about each of the people who are living or staying here. If an

OMB No. 0607-0919-DR; Approval Expires 8/30/2010

If more people were counted in Question S2 on the front
page, continue with Person 2.

➜

If more people were counted in Question S2 on the front
page, continue with Person 3.

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201001

5-1-2007

Person 3

Person 4

1. What is the name of another person staying here who has no other place he/she usually lives?
First Name

1. What is the name of another person staying here who has no other place he/she usually lives?
First Name

MI

Last Name
2. Please look at List A. How is (Name) related to (Person 1’s Name)?
Husband or wife
Father or mother
Biological son or daughter
Grandchild
Adopted son or daughter
Parent-in-law
Stepson or stepdaughter
Son-in-law or daughter-in-law
Brother or sister
Other relative
3. Is (Name) male or female? Mark I
J
K ONE box.
Male
Female
4a. What is (Name’s) date of birth? Print numbers in boxes.
Day
Year
Month

Person 5

Mark I
J
K ONE box.
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

1. What is the name of another person staying here who has no other place he/she usually lives?
First Name

MI

Last Name
2. Please look at List A. How is (Name) related to (Person 1’s Name)?
Husband or wife
Father or mother
Biological son or daughter
Grandchild
Adopted son or daughter
Parent-in-law
Stepson or stepdaughter
Son-in-law or daughter-in-law
Brother or sister
Other relative
3. Is (Name) male or female? Mark I
J
K ONE box.
Male
Female
4a. What is (Name’s) date of birth? Print numbers in boxes.
Month
Day
Year

Mark I
J
K ONE box.
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

MI

Last Name
2. Please look at List A. How is (Name) related to (Person 1’s Name)?
Husband or wife
Father or mother
Biological son or daughter
Grandchild
Adopted son or daughter
Parent-in-law
Stepson or stepdaughter
Son-in-law or daughter-in-law
Brother or sister
Other relative
3. Is (Name) male or female? Mark I
J
K ONE box.
Male
Female
4a. What is (Name’s) date of birth? Print numbers in boxes.
Month
Day
Year

Person 6

Mark I
J
K ONE box.
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

4b. What is (Name’s) age on April 1, 2008? Record babies as age 0 when the child is less

than 1 year old.

than 1 year old.

Age

Age

MI

Last Name

Date of Birth
Month
Day

Person 7

Age on April 1, 2008
Year

First Name

5. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?

5. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

No, not of Hispanic, Latino, or Spanish origin
Yes — Is (Name) Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of
another Hispanic, Latino, or Spanish origin, for example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Yes, another Hispanic, Latino, or
Spanish origin — What is that group? C

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

Yes, another Hispanic, Latino, or
Spanish origin — What is that group? C

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

Yes, another Hispanic, Latino, or
Spanish origin — What is that group? C

6. Please look at List C and choose one or more races. For this census, Hispanic origins are

6. Please look at List C and choose one or more races. For this census, Hispanic origins are

not races. Is (Name) White; Black, African American, or Negro; American Indian or Alaska
Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

not races. Is (Name) White; Black, African American, or Negro; American Indian or Alaska
Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

not races. Is (Name) White; Black, African American, or Negro; American Indian or Alaska
Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?
White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

Date of Birth
Month
Day

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

White
Black, African Am., or Negro
American Indian or Alaska Native — What is the name of the enrolled or principal tribe? C

Person 8

MI

Age on April 1, 2008
Year

First Name

MI

Last Name

Date of Birth
Month
Day

Person 9

Age on April 1, 2008
Year

First Name

MI

Last Name
Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Chinese
Korean

Filipino
Vietnamese

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?
Asian Indian
Japanese

Other Asian — What is that group? C

Native Hawaiian
Samoan

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

If more people were counted in Question S2 on the
front page, continue with Person 4.

Location of PID barcode

Asian Indian
Japanese

Other Asian — What is that group? C

➜

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

If more people were counted in Question S2 on the
front page, continue with Person 5.

Chinese
Korean

Filipino
Vietnamese

Other Asian — What is that group? C

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Some other race — What is this group? C

Some other race — What is this group? C

➜

Filipino
Vietnamese

Related to Person 1?

Sex
Male
Female

Related to Person 1?
Yes
No
Sex
Male
Female

Related to Person 1?
Yes
No
Sex
Male
Female

Asian — Is (Name) Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another
Asian group, (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)?

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?

Native Hawaiian or Other Pacific Islander — Is (Name) Native Hawaiian, Guamanian or Chamorro,
Samoan, or another Pacific Islander group, (for example, Fijian, Tongan, and so on)?
Native Hawaiian
Samoan

Chinese
Korean

Sex
Male
Female

Yes
No

Age

5. Please look at List B on the Information Sheet. Is (Name) of Hispanic, Latino, or Spanish origin?

6. Please look at List C and choose one or more races. For this census, Hispanic origins are

First Name

Last Name

than 1 year old.

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

I have a few questions about each of the other people living or
staying in this (RV/boat/room/unit).

Guamanian or Chamorro
Other Pacific Islander — What is that group? C

Some other race — What is this group? C

➜

If more people were counted in Question S2 on the
front page, continue with Person 6.

Date of Birth
Month
Day

Person 10

Age on April 1, 2008
Year

First Name

MI

Last Name

Date of Birth
Month
Day

Age on April 1, 2008
Year

Related to Person 1?
Yes
No
Sex
Male
Female

Related to Person 1?
Yes
No

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201002