2016 Census Test - Focus Group Selection Contacts

ID #

Focus Group Worksheet

2016 Census Test

This information will not be used to contact you. Your response is voluntary and will only be used for research purposes.

1. What is your name?

_____________________ _____________________

First Last

2. What is your address?

Street number and name: ____________________________________________

Apartment or unit number: ___________________________________________

City: ____________________________________________

State: _____________________

ZIP Code: _________________

3. How many people are living or staying at this address?

________

4. Please provide a phone number where you can be reached.

( ________ ) - ________ - ___________

5. Please provide an email address where you can be reached.

_______________________________________ @ __________________ . _________

OMB Control Number: 0607-0989