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pdfAttachment A
OMB No. XXXX-XXXX
COVERAGE
C1.
FORM SC-1
(04-09-2012) Draft 21
U.S. DEPARTMENT OF COMMERCE
SC ID
State
County
Tract
Economics and Statistics Administration
U.S. CENSUS BUREAU
I need to make sure I have counted everyone who lived or stayed here on (Special Census Date). Did I miss —
– any children, including babies or foster children?
– any other relatives?
– any roommates?
– any other nonrelatives?
– anyone else staying here on (Special Census Date) who had no permanent place to live?
ENUMERATOR
QUESTIONNAIRE
Yes – Add person(s) to question 1, mark the "Add" box, and ask questions 2—6. Correct the POP count in question S5 on the front cover.
Block
AA
Map Spot
Barcode ID
Special Census
No – Continue with C2.
On (Special Census Date), were any of the people you told me about living or staying somewhere else for any of these reasons:
– in college housing?
– in the military?
– in jail or prison?
– in a nursing home?
Yes – Delete person(s) from question 1 by marking the "Cancel" box. Correct the POP count in question S5 on the front cover.
Is this an added unit or is
there a change to the
preprinted address label?
HOUSING
H2.
Do you or does someone in this household own this (house/apartment/mobile home) with a mortgage or loan, including
home equity loans; own it free and clear; rent it; or occupy it without having to pay rent?
Yes – Enter the full
address in the address
change section ➔
Own free and
Own with a mortgage
clear (without a
or loan (including
mortgage or loan)
home equity loans)
What type of structure is this unit?
No – Skip to S1
Single Family Structure
RESPONDENT INFORMATION
R1.
Rent
Multi-Unit Structure
R2.
Enter respondent’s name.
Occupy without
payment of rent
Mobile Home
In case we need to contact you, what is
your telephone number, address, and the
best time to call?
Mark box with a Letter:
R (Rural Route)
L (Location Description)
Boat/Tent/Other
R3.
R4.
Respondent —
First Name
Lived here on
Special Census
Date
Are there any other
living quarters either
occupied or vacant
at this address?
Yes (List unit on
SC-921(HU) Add
page, if it is not
listed on the
SC-920(HU)
Listing Sheet, and
complete a blank
SC-1)
Moved in after
Special Census
Date
Last Name
Is neighbor or
other proxy
INTERVIEW SUMMARY
A.
Number of continuation forms
for this address
ADDED UNIT ADDRESS or ADDRESS CHANGES
No – Continue with H1.
H1.
Unit Status on Special Census Date
B.
POP on Special
Census Date
C.
No
D.
If vacant, ask: Which category best
describes this vacant unit as of
(Special Census Date)? (Read categories.)
E.
PI
REP
House Number
(R or L)
RECORD OF CONTACT
OUTCOME CODES:
§!++/¤
1
2
3
4
5
6
7
8
=
=
=
=
=
=
=
=
Occupied
Vacant – regular
Vacant – usual home elsewhere
Demolished
Burned out/cannot locate/outside block
Nonresidential
Empty mobile home/trailer site
Uninhabitable (open to elements,
condemned, under construction)
9 = Duplicate of Barcode ID belowC
01–49 = Total persons
00 = Vacant
98 = Delete
99 = POP unknown
CO
G.
REF
Rented, not occupied
✗
Personal
Time
Outcome
/
:
a.m.
p.m.
Telephone
/
:
a.m.
p.m.
Personal
Telephone
/
:
a.m.
p.m.
CI = Conducted
Interview
Personal
Telephone
/
:
a.m.
p.m.
OT = Other
Personal
Telephone
/
:
a.m.
p.m.
Personal
Telephone
/
:
a.m.
p.m.
RE = Refusal
INTRODUCTION
For sale only
TU
S4.
Hello, I’m (Name) from the U.S. Census Bureau.
(Show ID). Is this (Address)?
(Only ask if no household member lived here on Special Census
Date.) On (Special Census Date), was this unit vacant, or
occupied by a different household?
Vacant – Skip to question H2 on the back page.
Yes – Continue with question S2
Sold, not occupied
For seasonal, recreational,
or occasional use
I.
J. JIC2
JIC1
S2.
For migrant workers
No – Ask: Can you tell me where to find (Address)?
END INTERVIEW.
I’m here to complete a Special Census questionnaire for this
address. It should take about 10 minutes. (Hand respondent
an Information Sheet.) The first part explains that your
answers are confidential. I’ll refer to the other parts later.
Did you or anyone in this household live or stay here on
(Special Census Date)?
Yes – Continue with question S3.
I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.
Enumerator’s signature
Year
Day
Personal
CERTIFICATION
Day
Month
NC = No Contact
Other vacant
Month
Zip Code
Write either Rural Route or Location Description in the box below.
Type:
NV = Left Notice
of Visit
S1.
H.
Street Name
Apartment Number/Unit Designation
For rent
F.
APPLY PREPRINTED LABEL HERE
Continuation form(s) attached
Employee ID Code
No – Skip to question S4.
Crew Leader’s
initials
CLD number
Month
Year
Day
S3.
Does someone usually live at this
(house/apartment/mobile home), or is this a vacation
or seasonal home?
Occupied by a different household – Using a knowledgeable
respondent, complete this questionnaire for the Census Date
household.
Not a housing unit – Skip to "Respondent Information" on
back page.
S5.
We need to count people where they live and sleep most
of the time.
Please look at list A. It contains examples of people who
should and should not be counted at this place.
Based on these examples, how many people were living
or staying in this (house/apartment/mobile home) on
(Special Census Date)?
Usually lives here – Skip to question S5.
Vacation or seasonal home or held for occasional use –
Skip to question H2 on the back page.
Number of people
00101014
C2.
Let’s make a list of all those people. Please
start with the name of an owner or renter
who was living here on (Special Census Date).
Otherwise, start with any adult living here.
Person 1
2.
Please look at list B on the Information Sheet.
How is (Name) related to (Read name of Person 1)?
Mark ✗ ONE box.
✗
First Name
3.
Is (Name) male or
female?
Mark ✗ ONE box.
Male
Person 1
4. What was (Name’s) age on (Special Census
Date)? What is (Name’s) date of birth?
Please report babies as age 0 when the child
is less than 1 year old. Print numbers in boxes.
Female
Age on
Special Census Date
MI
DATE OF BIRTH
5. Please look at List C. Is (Name) of Hispanic, 6. Please look at List D and choose one or more races. For this Special Census, Hispanic origin
Latino, or Spanish origin?
Read if necessary: Examples of another Hispanic, Latino, or
Spanish origin include Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.
White
Black or
African
American
American
Indian or
Alaska
Native
Yes, Puerto Rican
Asian
Indian
Chinese
Filipino
Yes, Cuban
Japanese
Korean
Vietnamese
Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C
Native
Hawaiian
Guamanian
or Chamorro
Samoan
No, not of Hispanic, Latino, or
Spanish origin
Yes, Mexican, Mexican American,
Chicano
Last Name
Month
Day
Cancel
Add
First Name
MI
Last Name
Cancel
Add
Person 3
First Name
MI
Last Name
Cancel
Add
Person 4
First Name
MI
Husband
or wife
Grandchild
Unmarried
partner
Biological son
or daughter
Parent-in-law
Other
nonrelative
§!++7¤
Last Name
Add
Person 5
First Name
MI
Last Name
Cancel
FORM SC-1 (04-09-2012) Draft 21
Add
Male
Female
Age on
Special Census Date
DATE OF BIRTH
Adopted son
or daughter
Son-in-law or
daughter-in-law
Stepson or
stepdaughter
Other relative
Brother or
sister
Roomer or boarder
Father or
mother
Housemate or roommate
Husband
or wife
Grandchild
Unmarried
partner
Biological son
or daughter
Parent-in-law
Other
nonrelative
Adopted son
or daughter
Son-in-law or
daughter-in-law
Stepson or
stepdaughter
Other relative
Brother or
sister
Roomer or boarder
Father or
mother
Housemate or roommate
Husband
or wife
Grandchild
Unmarried
partner
Parent-in-law
Other
nonrelative
Biological son
or daughter
Cancel
Some other race — What is that group?
Year of birth
Person 2
Month
Day
Female
Age on
Special Census Date
DATE OF BIRTH
Month
Day
Female
Age on
Special Census Date
DATE OF BIRTH
Adopted son
or daughter
Son-in-law or
daughter-in-law
Stepson or
stepdaughter
Other relative
Brother or
sister
Roomer or boarder
Father or
mother
Housemate or roommate
Husband
or wife
Grandchild
Biological son
or daughter
Parent-in-law
Month
Day
Asian
Indian
Chinese
Filipino
Yes, Cuban
Japanese
Korean
Vietnamese
Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Other
nonrelative
Adopted son
or daughter
Son-in-law or
daughter-in-law
Stepson or
stepdaughter
Other relative
Brother or
sister
Roomer or boarder
Father or
mother
Housemate or roommate
Male
Female
Age on
Special Census Date
DATE OF BIRTH
Month
Day
Year of birth
Other Asian —
➤
American
Indian or
Alaska
Native
Yes, Puerto Rican
Asian
Indian
Chinese
Filipino
Yes, Cuban
Japanese
Korean
Vietnamese
Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Some other race — What is that group?
Other Asian —
➤
American
Indian or
Alaska
Native
Yes, Puerto Rican
Asian
Indian
Chinese
Filipino
Yes, Cuban
Japanese
Korean
Vietnamese
Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Some other race — What is that group?
Other Asian —
➤
American
Indian or
Alaska
Native
Yes, Puerto Rican
Asian
Indian
Chinese
Filipino
Yes, Cuban
Japanese
Korean
Vietnamese
Yes, another Hispanic, Latino, or
Spanish origin — What is that origin? C
Native
Hawaiian
Guamanian
or Chamorro
Samoan
Some other race — What is that group?
What is that
Other Pacific
Islander — What is that group?
Black or
African
American
Yes, Mexican, Mexican American,
Chicano
What is the name of the enrolled or
principal tribe? C
group? C
White
No, not of Hispanic, Latino, or
Spanish origin
What is that
Other Pacific
Islander — What is that group?
Black or
African
American
Yes, Mexican, Mexican American,
Chicano
What is the name of the enrolled or
principal tribe? C
group? C
White
No, not of Hispanic, Latino, or
Spanish origin
What is that
Other Pacific
Islander — What is that group?
Black or
African
American
Yes, Mexican, Mexican American,
Chicano
What is the name of the enrolled or
principal tribe? C
group? C
White
No, not of Hispanic, Latino, or
Spanish origin
Year of birth
Unmarried
partner
➤
Yes, Puerto Rican
Some other race — What is that group?
What is that
Other Pacific
Islander — What is that group?
American
Indian or
Alaska
Native
Year of birth
Male
Other Asian —
Black or
African
American
Yes, Mexican, Mexican American,
Chicano
What is the name of the enrolled or
principal tribe? C
group? C
White
No, not of Hispanic, Latino, or
Spanish origin
Year of birth
Male
is not a race. What is (Name’s) race?
Read if necessary: Examples of other Asian groups include Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on. Examples of other Pacific Islander groups include Fijian, Tongan, and so on.
What is the name of the enrolled or
principal tribe? C
Other Asian —
What is that
group? C
Other Pacific
Islander — What is that group?
➤
00101022
1.
| File Type | application/pdf |
| File Title | sc1_p1.g |
| File Modified | 2012-05-24 |
| File Created | 2012-04-09 |