Paper Census Household Form
GENERAL INSTRUCTIONS
Who should use this paper form?
Anyone who, on January 15, 2012, was living or staying at the address printed on this form.
Anyone who lives and sleeps most of the time at the address printed on this form.
Anyone whose entire household moved into this address on or before January 15, 2012.
Who should respond online?
Anyone whose entire household moved into this address printed on this form after January 15, 2012.
Anyone who needs to report that the address printed on this form was vacant on January 15, 2012.
Anyone who needs to report that the address printed on this form is a seasonal home.
CENSUS QUESTIONS
T
= Number of people for Question #1
Certain types of people are sometimes left off the census. Were there any additional people staying here January 15, 2012 that you did not include in Question #1, for example:
Yes No Babies?
Yes No Foster children?
Yes No Any other relatives?
Yes No Roommates or people not related to you?
Yes No People staying here temporarily?
Y
= Number of ADDITIONAL people for Question #2
Is this house, apartment or mobile home—Mark X ONE box
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
W
On the inside of this form, list all the people reported in Question 1 and Question 2.
Person
1 Please
provide information for each person counted in Questions #1 and #2.
Start with a person living here who owns or rents this house,
apartment, or mobile home. If the owner or renter lives somewhere
else, start with any adult living here. This will be person 1. What
is Person 1’s name? Print
name below First
Name
MI
Last
Name
What
is Person 1’s sex? Mark
X ONE box. Male Female What
is Person 1’s age and what is Person 1’s date of birth?
Please
report babies as age 0 when the child is less than 1 year old. Print
Numbers in Boxes Age
on January 15, 2012 Month Day Year of Birth
Is
Person 1 of Hispanic, Latino, or Spanish Origin? No,
not
of Hispanic, Latino, or Spanish origin Yes,
Mexican, Mexican American, Chicano Yes,
Puerto Rican Yes,
Cuban Yes,
another Hispanic, Latino, or Spanish origin---Print
origin, for example, Argentinean, Columbian, Dominican, Nicaraguan,
Salvadorian, Spaniard, and so on
What
is Person 1’s race? Mark
X one or more boxes. White Black,
African American, or Negro American
Indian or Alaska Native—Print
name of enrolled or principal tribe
Some
other race—Print
race
Continue
to Question 10
Some
people live or stay in more than one place and we would like to make
sure everyone is only counted once.
Does
Person 1 sometimes live or stay somewhere else? Yes—Mark
X all that apply
No
On
January 15, 2012, did Person 1 stay in another type of place? Yes-Mark
X all that apply
No
Did
person 1 move during January? Yes—what
date? ___________________ No
If
you marked yes to Question 10, 11, or 12 please provide the full
address of the other
place
:
If
there is more than one place, provide the other
address where you were most of the time.
Street
Address (House Number and Street Name)
Apartment
Number
City State Zip
Code
County
NOTE:
If you do not know the address, provide the neighborhood or
community, cross streets or facility name:
Where
does Person 1 live or stay most of the time? The
address printed on the back of this questionnaire The
address or location listed in Question 13. Both
places equally Some
other place
On
January 15, 2012, where
was Person 1 staying? The
address printed on the back of this questionnaire The
address or location you listed in Question 13. Some
other place
If more people were counted in Question 1 or 2, continue with Person
2.
For
College (on or off campus) In
the Military For
a job or business With
a parent or grandparent
At
another home, like a second or seasonal home Another
place
In
jail or prison In
a nursing home or group home Another
place
Native
Hawaiian Guamanian
or Chamorro Samoan Other
Pacific Islander—Print
race, for example, Fijian, Tongan, and so on Asian
Indian Chinese Filipino
Other
Asian—Print
race, for example Hmong, Laotian, Thai, Pakistani, Cambodian, and
so on Japanese Korean Vietnamese
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | smirn001 |
File Modified | 0000-00-00 |
File Created | 2021-02-02 |