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DX-1303 (05/01/2007)
U.S. DEPARTMENT OF COMMERCE
OMB No. XXXX-XXXX:
Approval Expires XX/XX/20XX
Economics and Statistics Administration
FORM
U.S. CENSUS BUREAU
Census Coverage Measurement (CCM)
Initial Housing Unit Followup (IHUFU) Packet Cover Page
2008 Census Dress Rehearsal
A. Cluster Identification
B. Followup Units in Packet
1. Cluster No.
Block Number
2. LCO name
3. Code
4. County
5. Code
6. State
7. Code
Number of Followup
Units per Block
8. TEA
Total Number of Followup Units______
C. Field Staff Identification
Dates
Position
Name
Applicant ID
(a)
1. Crew leader
(b)
(c)
Assigned
(e)
Month
Day
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2. Interviewer
3. Interviewer
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Completed
(f)
Month
Day
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CENSUS CONFIDENTIAL: RESTRICTED DATA FOR OFFICIAL USE ONLY. Information contained in this report is for use by the
Census Bureau and is confidential by law (Title 13, U.S.C.). It may be seen only by sworn Census employees and may be used only for
statistical purposes.
NOTICE TO FINDER: If found, please either call 1-301-763-3301 to arrange for pickup OR mail to: Census Coverage Measurement,
U.S. Census Bureau, 4600 Silver Hill Road, Washington, DC 20277-6081, Attn: CCM Field Staff
Locating Instructions
If you cannot locate the address, or have trouble determining whether it is the same as another address on your list:
1. Look within and outside the cluster
2. Approach a householder, apartment/building manager, neighbor, postal worker/letter carrier, etc., and use this
introduction as a guide:
Hello. I am (your name) from the Census Bureau. Here is my identification. We are checking addresses in
this area as part of the 2008 Census Dress Rehearsal. Here is some information about what we are doing.
The questions should only take 3 minutes. (Hand the respondent a Privacy Act Notice and allow time for him
or her to read it.)
3. Ask the following questions as needed:
3a. Was (street name) ever known by another name?
3b. Did or does the house/apartment at (address) ever use a different address?
3c. Is (address) ever identified in any other way?
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 2 of 69
PAGE: 1 of 2
.
CCM Nonmatched Address (NI)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS
1.
Is there a housing unit at CCM ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): _____________________________________________________________
No → Please describe the status of CCM ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: _________________________________________________
Describe facility: ___________________________________________________
___________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
________________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
____________________________________________________________________________________ → 6
2.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS? ⏐
3.
⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS?
Yes
(E)
→ Enter Census ID: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 3 of 69
PAGE: 2 of 2
CCM Nonmatched Address (NI)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS
4.
Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box at the
top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS?
Yes
(F1)
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ and WMSN ⏐ ⏐ ⏐ ⏐ ⏐
No
5.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
6.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
7.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 4 of 69
PAGE: 1 of 2
.
Census Nonmatched Address (NE)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS
1.
Is there a housing unit at CENSUS ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): _____________________________________________________________
No → Please describe the status of CENSUS ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: _________________________________________________
Describe facility: ___________________________________________________
___________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
________________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
____________________________________________________________________________________ → 6
2.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS
(B)
Yes
No → In what block number is CENSUS ADDRESS?⏐
3.
⏐⏐⏐⏐⏐⏐
(B1)
Are there any addresses listed in the CCM column of the Housing Unit Reference List that represent the same
housing unit as CENSUS ADDRESS?
Yes
No
(D)
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ and WMSN ⏐ ⏐ ⏐ ⏐ ⏐
→ Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 5 of 69
PAGE: 2 of 2
Census Nonmatched Address (NE)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS
4.
Look at the Census column of the Housing Unit Reference List. Notice that the address in the Census Address box at (G1)
the top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CENSUS ADDRESS?
Yes
→
Enter Census ID: ⏐
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
5.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
6.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
7.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 6 of 69
PAGE: 1 of 4
.
Possible CCM-Census Match (P)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
XXXXX
CCM ADDRESS
CENSUS ADDRESS
[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as
another.]
1.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS
Census Address: CENSUS ADDRESS
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS
CENSUS ADDRESS
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
CCM ADDRESS
2.
Is there a housing unit at CCM ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 12
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 7 of 69
PAGE: 2 of 4
.
Possible CCM-Census Match (P)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
MSN
XXXXX
XXXXX
CCM ADDRESS
3.
Census ID
CENSUS ADDRESS
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
5.
Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box
at the top of this form is already listed in that column. Aside from that address, do any other addresses in that
column refer to the same housing unit as CCM ADDRESS ?
Yes
→ Enter CCM MSN⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
(F1)
⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 8 of 69
PAGE: 3 of 4
.
Possible CCM-Census Match (P)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
Census ID
MSN
XXXXX
XXXXX
CCM ADDRESS
CENSUS ADDRESS
CENSUS ADDRESS
7.
Is there a housing unit at CENSUS ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→12
8.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS
(B)
Yes
No → In what block number is CENSUS ADDRESS?
9.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS?
Yes
No
(D)
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ and WMSN ⏐ ⏐ ⏐ ⏐ ⏐
→ Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 9 of 69
PAGE: 4 of 4
Possible CCM-Census Match (P)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit
Status
# Units
Block
MSN
XXXXX
XXXXX
CCM ADDRESS
10.
Census ID
CENSUS ADDRESS
Look at the Census column of the Housing Unit Reference List. Notice that the address in the Census Address box
at the top of this form is already listed in that column. Aside from that address, do any other addresses in that
column refer to the same housing unit as CENSUS ADDRESS?
Yes
→
Enter Census ID: ⏐
(G1)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
11.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
12.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
13.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 10 of 69
PAGE: 1 of 3
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
XXXXX
# Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as
another address.]
1.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 11 of 69
PAGE: 2 of 3
.
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es)
Block
MSN
WMSN
Census Address(es)
TOA
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
2.
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 7
3.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 12 of 69
PAGE: 3 of 3
CCM-Census Match/Duplicate CCM Address (M/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
5.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
7.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
8.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 13 of 69
PAGE: 1 of 3
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
XXXXX
# Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
[See LOCATING INSTRUCTIONS on the Cover Page if you are having trouble determining whether one address is the same as
another address.]
1.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 14 of 69
PAGE: 2 of 3
.
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
2.
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 7
3.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS 2?
Yes
No
(D)
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ and WMSN ⏐ ⏐ ⏐ ⏐ ⏐
→ Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 15 of 69
PAGE: 3 of 3
CCM-Census Match/Duplicate Census Address (M/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
5.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
7.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
8.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 16 of 69
PAGE: 1 of 5
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
FIRST CCM DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 17 of 69
PAGE: 2 of 5
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
2.
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 13
3.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 18 of 69
PAGE: 3 of 5
.
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es)
Block
MSN
WMSN
Census Address(es)
TOA
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
4.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
5.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
7.
Do the following address refer to the same housing unit?
CCM Adress: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 19 of 69
PAGE: 4 of 5
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es)
Block
MSN
WMSN
Census Address(es)
TOA
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
8.
Is there a housing unit at CCM ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 3
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 13
9.
Is CCM ADDRESS 3 located in block XXXXX?
(B)
Yes
No → In what block number is CCM ADDRESS 3?
10.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 3?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 20 of 69
PAGE: 5 of 5
CCM-Census Match/Two Duplicate CCM Addresses (M/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
11.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 3?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
12.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
13.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
14.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 21 of 69
PAGE: 1 of 5
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
FIRST CENSUS DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CNESUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 22 of 69
PAGE: 2 of 5
.
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
2.
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 13
3.
Is this address located in block XXXXX?
CENSUS Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 2?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 23 of 69
PAGE: 3 of 5
.
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
5.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
7.
Do the following addresses refer to the same housing unit?
Census address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 3
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 24 of 69
PAGE: 4 of 5
.
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE )
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
8.
Is there a housing unit at CENSUS ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 3
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 13
9.
Is CENSUS ADDRESS 3 located in block XXXXX?
(B)
Yes
No → In what block number is CENSUS ADDRESS 3?
10.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 3?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 25 of 69
PAGE: 5 of 5
CCM-Census Match/Two Duplicate Census Addresses (M/DE/DE )
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit
Status
# Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
11.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 3?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
12.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
13.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
14.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 26 of 69
PAGE: 1 of 4
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
CCM DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
(C)
What is the correct address?
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
2.
No
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 12
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 27 of 69
PAGE: 2 of 4
.
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
3.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
5.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 28 of 69
PAGE: 3 of 4
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
CCM Nonmatch
7.
Is there a housing unit at CCM ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 1.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 12
8.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 1
(B)
Yes
No → In what block number is CCM ADDRESS 1?
9.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 1?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 29 of 69
PAGE: 4 of 4
CCM Nonmatched and Duplicate Addresses (NI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
10.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 1?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
11.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
12.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
13.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 30 of 69
PAGE: 1 of 4
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
CENSUS DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
Census address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
(C)
What is the correct address?
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
2.
No
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 12
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 31 of 69
PAGE: 2 of 4
.
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
3.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 2?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
⏐⏐⏐⏐⏐
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
5.
(B1)
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 32 of 69
PAGE: 3 of 4
.
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
7.
CENSUS Nonmatch
Is there a housing unit at CENSUS ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 1.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 12
8.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 1
(B)
Yes
No → In what block number is CENSUS ADDRESS 1?
9.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 1?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 33 of 69
PAGE: 4 of 4
Census Nonmatched and Duplicate Addresses (NE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
10.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 1?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
11.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
12.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
13.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 34 of 69
PAGE: 1 of 2
.
Unit Status Update or Surrounding Block Match (M*)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit Status # Units
Block
XXXXX
MSN
XXXXX
CCM ADDRESS
1.
Census ID
CENSUS ADDRESS
Is there a housing unit at CCM ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 4
2.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS?
3.
⏐⏐⏐⏐⏐⏐⏐
(B1)
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 35 of 69
PAGE: 2 of 2
Unit Status Update or Surrounding Block Match (M*)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS
4.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
5.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 36 of 69
PAGE: 1 of 3
.
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CENSUS ADDRESS
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
1.
Is there a housing unit at CCM ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 1.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 10
2.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 1
(B)
Yes
No → In what block number is CCM ADDRESS 1?
3.
⏐⏐⏐⏐⏐⏐⏐
(B1)
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 37 of 69
PAGE: 2 of 3
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
XXXXX
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
CCM DUPLICATE RECORD
4.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
(C)
What is the correct address?
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
5.
No
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 10
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 38 of 69
PAGE: 3 of 3
Unit Status Update or Surrounding Block Match/Duplicate CCM Address (M*/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
XXXXX
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
6.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
7.
⏐⏐⏐⏐⏐⏐⏐
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(B1)
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
8.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2, besides the addresses listed in the boxes above?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
9.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
10.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
11.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 39 of 69
PAGE: 1 of 3
.
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
1.
Is there a housing unit at CCM ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 10
2.
Is this address located in block XXXXX?
Census Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS?
3.
⏐⏐⏐⏐⏐⏐⏐
(B1)
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 40 of 69
PAGE: 2 of 3
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
XXXXX
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
CCM ADDRESS
XXXXX
CENSUS ADDRESS 2
CENSUS DUPLICATE RECORD
4.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
(C)
What is the correct address?
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
5.
No
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 10
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 41 of 69
PAGE: 3 of 3
Unit Status Update or Surrounding Block Match/Duplicate Census Address (M*/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
XXXXX
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
CCM ADDRESS
XXXXX
CENSUS ADDRESS 2
6.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
7.
⏐⏐⏐⏐⏐⏐⏐
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 2?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
⏐⏐⏐⏐⏐
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
8.
(B1)
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
9.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
10.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
11.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 42 of 69
PAGE: 1 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
1.
Is there a housing unit at CCM ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 1
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
2.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 1
(B)
Yes
No → In what block number is CCM ADDRESS 1?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 43 of 69
PAGE: 2 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
3.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
FIRST CCM DUPLICATE RECORD
4.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
XXXXX
Other _________________________________________________
No
(C2)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 44 of 69
PAGE: 3 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
5.
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
6.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 45 of 69
PAGE: 4 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
7.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
8.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
9.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
10.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CCMA ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block?
XXXXX
Other _________________________________________________
No
(C2)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 46 of 69
PAGE: 5 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
11.
Is there a housing unit at CCM ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 3
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
12.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 3
(B)
Yes
No → In what block number is CCM ADDRESS 3?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 47 of 69
PAGE: 6 of 6
Unit Status Update or Surrounding Block Match/Two Duplicate CCM Addresses
(M*/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS 1
CENSUS ADDRESS
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
13.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 3?
Yes
→
Enter Census ID: ⏐
(E)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
14.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box
(F2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that
column refer to the same housing unit as CCM ADDRESS 3?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
15.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
16.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
17.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 48 of 69
PAGE: 1 of 6
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
1.
Is there a housing unit at CCM ADDRESS?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
2.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 49 of 69
PAGE: 2 of 6
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
3.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
FIRST CENSUS DUPLICATE RECORD
4.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
XXXXX
Other _________________________________________________
No
(C2)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 50 of 69
PAGE: 3 of 6
.
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
5.
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2
(A1)
Under construction or future construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
6.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
7.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the
same housing unit as CENSUS ADDRESS 2?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 51 of 69
PAGE: 4 of 6
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
Census Address(es)
TOA
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
8.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
9.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
10.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block?
XXXXX
Other _________________________________________________
No
(C2)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 52 of 69
PAGE: 5 of 6
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
11.
Is there a housing unit at CENSUS ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 3
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 16
12.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 3
(B)
Yes
No → In what block number is CENSUS ADDRESS 3?
13.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS 3?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 53 of 69
PAGE: 6 of 6
Unit Status Update or Surrounding Block Match /Two Duplicate Census Addresses (M*/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
XXXXX
Census ID
MSN
XXXXX
CCM ADDRESS
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
14.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address
box at the top of this form are already listed in that column. Aside from those addresses, do any other addresses
in that column refer to the same housing unit as CENSUS ADDRESS 3?
Yes
→
Enter Census ID: ⏐
(G2)
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
15.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
16.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
17.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 54 of 69
PAGE: 1 of 7
CCM Nonmatched/Two Duplicate CCM Adresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
FIRST CCM DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 55 of 69
PAGE: 2 of 7
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
2.
Is there a housing unit at CCM ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 2.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
3.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 2
(B)
Yes
No → In what block number is CCM ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 2?
Yes
(E)
→ Enter Census ID: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 56 of 69
PAGE: 3 of 7
.
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
5.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 2?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CCM DUPLICATE RECORD
7.
Do the following addresses refer to the same housing unit?
CCM Address: CCM ADDRESS 1
CCM Address: CCM ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CCM ADDRESS 1
CCM ADDRESS 3
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 57 of 69
PAGE: 4 of 7
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
8.
Is there a housing unit at CCM ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 3.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
9.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 3
(B)
Yes
No → In what block number is CCM ADDRESS 3?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 58 of 69
PAGE: 5 of 7
.
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
10.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 3?
Yes
(E)
→ Enter Census ID: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
No
11.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 3?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
12.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 59 of 69
PAGE: 6 of 7
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
CCM NONMATCH RECORD
13.
Is there a housing unit at CCM ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CCM ADDRESS 1
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
14.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS 1
(B)
Yes
No → In what block number is CCM ADDRESS 1?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 60 of 69
PAGE: 7 of 7
CCM Nonmatched/Two Duplicate CCM Addresses (NI/DI/DI)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS 1
XXXXX
CCM ADDRESS 2
XXXXX
CCM ADDRESS 3
15.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS 3?
Yes
(E)
→ Enter Census ID: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
No
16.
Look at the CCM column of the Housing Unit Reference List. Notice that the addresses in the CCM address box at the (F2)
top of this form are already listed in that column. Aside from those addresses, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS 3?
Yes
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
and WMSN ⏐
⏐⏐⏐⏐
No
17.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
18.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
19.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 61 of 69
PAGE: 1 of 7
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
FIRST CENSUS DUPLICATE RECORD
1.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 2
Yes
→
What is the correct address?
(C)
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 2
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 62 of 69
PAGE: 2 of 7
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
2.
Is there a housing unit at CENSUS ADDRESS 2?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 2.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
3.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 2
(B)
Yes
No → In what block number is CENSUS ADDRESS 2?
4.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS 2?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 63 of 69
PAGE: 3 of 7
.
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
5.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box
(G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that
column refer to the same housing unit as CENSUS ADDRESS 2?
Yes
→
Enter Census ID: ⏐
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
6.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
SECOND CENSUS DUPLICATE RECORD
7.
Do the following addresses refer to the same housing unit?
Census Address: CENSUS ADDRESS 1
Census Address: CENSUS ADDRESS 3
Yes
→
What is the correct address?
(C)
(C1)
CENSUS ADDRESS 1
CENSUS ADDRESS 3
Other _________________________________________________
What is the correct block?
(C2)
XXXXX
Other _________________________________________________
No
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 64 of 69
PAGE:4 of 7
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
8.
Is there a housing unit at CENSUS ADDRESS 3?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 3.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
9.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 3
(B)
Yes
No → In what block number is CENSUS ADDRESS 3?
10.
⏐⏐⏐⏐⏐⏐⏐
(B1)
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS 3?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
(D)
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
⏐⏐⏐⏐⏐
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 65 of 69
PAGE: 5 of 7
.
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
11.
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box (G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that
column refer to the same housing unit as CENSUS ADDRESS 3?
Yes
→
Enter Census ID: ⏐
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
12.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 66 of 69
PAGE:6 of 7
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
CENSUS NONMATCH RECORD
13.
Is there a housing unit at CENSUS ADDRESS 1?
(A)
Yes, and address is correct
Yes, but address needs correction
(Write correct address here): __________________________________________________________________
No → Please describe the status of CENSUS ADDRESS 1.
(A1)
Under construction (doors, windows, or floors NOT in place)
Future construction
Unfit for habitation (condemned or open to the elements) and unoccupied
Demolished or burned down
Boarded up
Empty trailer lot/site or trailer/house has been moved
Group quarters → Enter facility name: ______________________________________________
Describe facility: _________________________________________________
_________________________________________________
Business
Unit used for storage
Other → Explain what is on the ground; continue on back and draw sketch map if needed
______________________________________________________________________________
Cannot locate → see LOCATING INSTRUCTIONS on the Cover page. If you still cannot locate address,
explain what is on the ground; continue on the back and draw a sketch map if needed.
_________________________________________________________________________________→ 18
14.
Is this address located in block XXXXX?
Census Address: CENSUS ADDRESS 1
(B)
Yes
No → In what block number is CENSUS ADDRESS 1?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 67 of 69
PAGE: 7 of 7
Census Nonmatched/Two Duplicate Census Addresses (NE/DE/DE)
CCM Address(es)
Block
MSN
WMSN
TOA
Census Address(es)
Unit Status # Units
Block
Census ID
MSN
XXXXX
CENSUS ADDRESS 1
XXXXX
CENSUS ADDRESS 2
XXXXX
CENSUS ADDRESS 3
15.
Look at the CCM column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CENSUS ADDRESS 1?
Yes → Enter CCM MSN ⏐
⏐⏐⏐⏐⏐
and WMSN ⏐
⏐⏐⏐⏐
No → Add new map spot to the CCM Block Cluster Map, then enter the map spot number here: ⏐
16.
(D)
⏐⏐⏐⏐⏐
Look at the Census column of the Housing Unit Reference List. Notice that the addresses in the Census address box
(G2)
at the top of this form are already listed in that column. Aside from those addresses, do any other addresses in that
column refer to the same housing unit as CENSUS ADDRESS 1?
Yes
→
Enter Census ID: ⏐
⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐⏐
No
17.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
18.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
19.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
Attachment A
Page 68 of 69
PAGE:1 of 2
.
Group Quarters (GQ)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS
1.
Hello my name is (your name). I’m from the U.S. Census Bureau (show your identification badge). I’d like to speak
with someone who can answer questions about the type of place this is. Would that be you, or should I speak
with someone else?
(Continue, or if referred to another respondent, re-read paragraph above).
(H)
We are checking addresses in this area as part of the 2008 Census Dress Rehearsal. Here is some information
about what we are doing. The questions should take about 3 minutes. (Hand the person the Privacy Act Notice
and allow time for the person to read it.)
READ IF NECESSARY: I won’t need to interview residents here; I just want to ask some very basic questions about
the type of place this is.
2.
Next I’m going to show you a list [HAND FLASHCARD TO RESPONDENT]. Which of these best describes
this place?
A: Correctional facility
B: Dormitory, residence hall, fraternity or sorority house for students at a college, university, or seminary
C: Group home or residential treatment center
D: Health care facility or nursing home
E: Independent or assisted living facility WITH 24-hour skilled nursing unit or facility (ask for brochure)
F: Independent or assisted living facility WITHOUT 24-hour skilled nursing unit or facility (ask for brochure)
G: Recreational Vehicle (RV) park, campground, marina or racetrack
H: Religious group quarters
I: Residential school for people with disabilities
J: Shelter
K: Workers’ group living quarters or Job Corps center
L: None of the above
3.
Is this a private residence?
Yes
No
(I)
→9
→9
→9
→9
→4
→4
→5
→9
→9
→9
→9
→3
(J)
→5
→4
4.
Please describe this place: _________________________________________________________________________ (K)
_________________________________________________________________________
5.
Is this address located in block XXXXX?
CCM Address: CCM ADDRESS
(B)
Yes
No → In what block number is CCM ADDRESS?
⏐⏐⏐⏐⏐⏐⏐
(B1)
(Continued→)
Form DX-1303
OMB No. XXXX-XXXX
EXPIRES: XX/XX/20XX
.
Attachment A
Page 69 of 69
PAGE: 2 of 2
Group Quarters (GQ)
CCM Address
Block
MSN
WMSN
TOA
Census Address
Unit Status # Units
Block
Census ID
MSN
XXXXX
CCM ADDRESS
6.
Look at the Census column of the Housing Unit Reference List. Do any addresses in that column refer to the same
housing unit as CCM ADDRESS?
Yes
(E)
→ Enter Census ID: ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ ⏐
No
7.
Look at the CCM column of the Housing Unit Reference List. Notice that the address in the CCM address box at the
top of this form is already listed in that column. Aside from that address, do any other addresses in that column
refer to the same housing unit as CCM ADDRESS?
Yes
(F1)
→ Enter CCM MSN ⏐ ⏐ ⏐ ⏐ ⏐ ⏐ and WMSN ⏐ ⏐ ⏐ ⏐ ⏐
No
8.
How many housing units are at this basic street address?
(L)
One
More than one → How many? ____________
List all unit designations (eg: Apt. 12A, 12B, or for several units list ranges of all units,
e.g., Apts. 101-106, 201-206, 301-306) continue on the back if necessary:
______________________________________________________________________
______________________________________________________________________
(L1)
No housing units at this basic street address
9.
[Go to next question./Fill question or note from analyst beginning with: Special question:]
(M)
10.
Main source of information you used to fill out questions:
(N)
Household member
Building manager or landlord
Proxy
Observation
Notes:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
| File Type | application/pdf |
| File Title | NI Question Box |
| Author | Tony Rosenberger |
| File Modified | 2007-05-02 |
| File Created | 2007-05-02 |