SC-1(F) Information Sheet

Attachment M
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

INFORMATION SHEET
Special Census
Your Answers Are Confidential
Your participation in the special census is extremely
important and is needed in obtaining information about
your community. Although the individual responses are
voluntary, the information the special census receives from
you ensures the completeness and accuracy of the results.
We estimate that it will take about 10 minutes to complete
this interview. Respondents are not required to respond to
any information collected unless a valid approval number
has been assigned by the Office of Management and
Budget. The approval number for the Special Census is:
OMB No. 0607-0368.

If you have any comments regarding this census,
including suggestions for reducing its length, send it to:
Paperwork Reduction Project 0607-0368
U.S. Census Bureau
AMSD-3K138
4600 Silver Hill Road
Washington, DC 20233
You may e-mail comments to Paperwork@census.gov;
use Paperwork Project 0607-0368 as the subject.
Thank you for your cooperation. The U.S. Census
Bureau and your local government appreciate your help.
SC-1(F)

(6-8-2012)

DRAFT #7 (06/08/2012)

List A
WHO TO COUNT ON
SPECIAL CENSUS DAY
We need to count people where they
live and sleep most of the time.

Do NOT include:

Do include:

• College students who
live away from this
address most of the
year
• Armed Forces
personnel who live
away
• People in a nursing
home, mental hospital,
etc. on Special
Census Date

• Babies and children
living here, including
foster children

• People in jail, prison,
detention facility, etc.
on Special Census
Date

• Roommates
• Boarders
• People staying here
on Special Census
Date who have no
permanent place to
live

List B
RELATIONSHIP
Husband or wife

List C

List D

HISPANIC, LATINO, OR
SPANISH ORIGIN

RACE
(Choose one or more races.)

No, not of Hispanic, Latino,
or Spanish origin

White
American Indian or Alaska Native

Stepson or stepdaughter

Yes, Mexican, Mexican
American, or Chicano

Brother or sister

Yes, Puerto Rican

Chinese

Father or mother

Yes, Cuban

Filipino

Grandchild

Yes, another Hispanic, Latino,
or Spanish origin –
For example, Argentinean,
Colombian, Dominican,
Nicaraguan, Salvadoran,
Spaniard, and so on.

Japanese

Biological son or daughter
Adopted son or daughter

Parent-in-law
Son-in-law or daughter-in-law
Other relative
Roomer or boarder
Housemate or roommate
Unmarried partner
Other nonrelative

Black or African American
Asian Indian

Korean
Vietnamese
Other Asian – For example,
Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – For
example, Fijian, Tongan,
and so on.
Some other race

SC-1(F) (6-8-2012)