SC-2 Individual Census Report

Attachment D
FORM SC-2
(05-10-2012) Draft 13

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

OMB No. XXXX-XXXX

SC ID

Barcode ID

U.S. CENSUS BUREAU

GQ Name

Special Census
Individual Census
Report

➤

➤

APPLY PREPRINTED LABEL HERE

Person Number

5. Please look at List D and choose one or more races.
What is your race? Mark ✗ one or more boxes.
White

1. What is your name? Print name below.

Black or African American

First Name

MI

American Indian or Alaska Native – Print name
of enrolled or principal tribe. C
Last Name

2. What is your sex? Mark ✗ ONE box.
Male

Female

3. What was your age on (Special Census Date) and what is your
date of birth?
Please report babies as age 0 when the child is less than 1 year old.
Age on Special
Census Date

Print numbers in boxes.
Month

Day

Year of birth

➜ NOTE: Please answer BOTH Question 4 about Hispanic origin
and Question 5 about race. For this Special Census, Hispanic
origins are not races.

Asian
Indian

Japanese

Native
Hawaiian

Chinese

Korean

Guamanian or
Chamorro

Filipino

Vietnamese

Samoan

Other Asian – Print
race, for example,
Hmong, Laotian, Thai,
Pakistani, Cambodian,
and so on. C

Other Pacific
Islander – Print
race, for example,
Fijian, Tongan,
and so on. C

Some other race – Print race. C

4. Please look at List C. Are you of Hispanic, Latino, or Spanish
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano

6. Do you live or stay in this facility MOST OF
THE TIME?
Yes

00121012

§!-+-¤

origin?

Yes, Puerto Rican
No
Yes, Cuban
INTERVIEW SUMMARY
Yes, another Hispanic, Latino, or Spanish origin – Print
origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on. C

A. JIC1

C. Answered By:

B. JIC2

Respondent

Other