Form SC-Q Housing Unit Enumerator Questionnaire

§8"?/¤

OMB No. XXXX-XXXX

Special Census Questionnaire

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

APPLY LABEL HERE

FOR NPC
USE ONLY

SCID

State

AA

County

Tract

Block

ADDED UNIT ADDRESS or ADDRESS CHANGES
Is this an added unit or
is there a change to the
preprinted address
label?

Address Number (example: 5007)

Street or Road Name (example: N Maple Ave)

Apartment Number/Unit Designation (example: Apt A or Lot 3)

Location Description
Rural Route or Location Description (if applicable)

AF

Yes, address changes ➜
Enter the full address to
the right.
No ➜ Skip to S1.

S1. Hello, I am (name) from the U.S. Census Bureau (show ID).

S5.

Is this (address)? If respondent says no, ask, “Can you tell
me where to find (address)?” and then end interview.

Is this [house/apartment/mobile home]
Mark I
K ONE box.
J

R

Owned by you or someone in this household with a
mortgage or loan, including home equity loans?

Respondent confirmed address.

Owned by you or someone in this household free and
clear, without a mortgage or loan?

S2. Did you or anyone in this household live or stay here on

D

(Special Census Day)?

Rural Route

T

Yes, added unit ➜
Enter the full address to
the right.

ZIP Code

Yes – I am here to complete a Special Census questionnaire
for this address. It should take about 10 minutes. (If you
haven’t already, hand respondent a confidentiality notice.)
This notice explains that your answers are confidential.

Rented?
Occupied without payment of rent?

S6.

No – Skip to S4.

S3. Does someone usually live at this
[house/apartment/mobile home], or is this a vacation or
seasonal home where no one usually lives?
Usually lives here – Skip to S5.

We need to count people where they live and sleep most
of the time. (Hand respondent an Information Sheet.) Please
read the WHO TO COUNT section on the Information
Sheet. Based on these instructions, how many people
were living or staying in this [house/apartment/mobile
home] on (Special Census Day)?
Number of people =

S7.

Vacation or seasonal home or held for occasional use – Skip
to “Respondent Information” on Page 8.

S4. On (Special Census Day), was this unit

Were there any additional people staying here on
(Special Census Day) that you did not include in the count
in the previous question? For example:
Mark I
K all that apply. Include any additional people on
J
the person pages.
Children, related or unrelated, such as newborn babies,
grandchildren, or foster children

Occupied by a different household? – Using a knowledgeable
respondent, complete this questionnaire for the people
occupying the household on (Special Census Day).

Relatives, such as adult children, cousins, or in-laws

Vacant? – Skip to “Respondent Information” on Page 8.

Nonrelatives, such as roommates or live-in babysitters

Not a housing unit – Skip to “Respondent Information”
on Page 8.

People staying here temporarily
No additional people
FORM

SC-Q

23013014

(07-25-2022) D7

§8"?7¤
Person 1
1. Now I am going to ask you questions about each person

5. Please read the RACE section on the Information Sheet.
What is Person 1’s race?
Mark I
K one or more boxes AND print origins.
J

living here. If there is someone living here who pays the
rent or owns this residence, I would like to start by listing
him or her as Person 1. If the owner or the person who
pays the rent does not live here, I can start by listing any
adult living here as Person 1.

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

What is Person 1’s name?
Print name below and verify the spelling.
First Name

MI
Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Last Name(s)
American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

2. Is Person 1 male or female? Mark I
K ONE box.
J
Male

Female

3. What was Person 1’s age on (Special Census Day)? What is

Filipino

Korean

Samoan

Japanese

Chamorro

Asian Indian

Print numbers in boxes.
Month
Day
Year of birth

years

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

R

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

Some other race – Print race or origin. C

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is Person 1 of Hispanic, Latino, or Spanish origin?

D

4.

Native Hawaiian

AF

Age on (Special Census Day)

Vietnamese

T

Person 1’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.

Chinese

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 2 on the next page.

2

23013022

§8"??¤
Person 2
1. What is Person 2’s name?

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Print name below and verify the spelling.
First Name

MI

6.
Last Name(s)

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

2.

Yes, Mexican, Mexican Am., Chicano

Does this person usually live or stay somewhere else?
For example – Read the examples to respondent.
Mark I
K all that apply.
J
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

For another reason

For a job or business

No

Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

In a nursing home

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

4.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Other relative

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Roommate or housemate

D

Adopted son or daughter

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

AF

Opposite-sex husband/wife/spouse

Biological son or daughter

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

T

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark I
K ONE box.
J

R

3.

7. Please read the RACE section on the Information Sheet.

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Is this person male or female? Mark I
K ONE box.
J
Male

Female

5. What was this person’s age on (Special Census Day)? What is
this person’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.
Age on (Special Census Day)

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print numbers in boxes.
Month
Day
Year of birth

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

years
Some other race – Print race or origin. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 3 on the next page.

3

23013030

§8"?Q¤
Person 3
1. What is Person 3’s name?

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Print name below and verify the spelling.
First Name

MI

6.
Last Name(s)

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

2.

Yes, Mexican, Mexican Am., Chicano

Does this person usually live or stay somewhere else?
For example – Read the examples to respondent.
Mark I
K all that apply.
J
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

For another reason

For a job or business

No

Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

In a nursing home

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Stepson or stepdaughter
Brother or sister

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

R

Adopted son or daughter

T

Father or mother

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

AF

Opposite-sex husband/wife/spouse

Biological son or daughter

4.

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark I
K ONE box.
J

Other relative

Roommate or housemate

D

3.

7. Please read the RACE section on the Information Sheet.

Foster child

Other nonrelative

Is this person male or female? Mark I
K ONE box.
J
Male

Female

5. What was this person’s age on (Special Census Day)? What is
this person’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.
Age on (Special Census Day)

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print numbers in boxes.
Month
Day
Year of birth

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

years
Some other race – Print race or origin. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 4 on the next page.

4

23013048

§8"?X¤
Person 4
1. What is Person 4’s name?

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Print name below and verify the spelling.
First Name

MI

6.
Last Name(s)

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

2.

Yes, Mexican, Mexican Am., Chicano

Does this person usually live or stay somewhere else?
For example – Read the examples to respondent.
Mark I
K all that apply.
J
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

For another reason

For a job or business

No

Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

In a nursing home

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

4.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Other relative

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Roommate or housemate

D

Adopted son or daughter

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

AF

Opposite-sex husband/wife/spouse

Biological son or daughter

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

T

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark I
K ONE box.
J

R

3.

7. Please read the RACE section on the Information Sheet.

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Is this person male or female? Mark I
K ONE box.
J
Male

Female

5. What was this person’s age on (Special Census Day)? What is
this person’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.
Age on (Special Census Day)

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print numbers in boxes.
Month
Day
Year of birth

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

years
Some other race – Print race or origin. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 5 on the next page.

5

23013055

§8"?‘¤
Person 5
1. What is Person 5’s name?

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Print name below and verify the spelling.
First Name

MI

6.
Last Name(s)

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

2.

Yes, Mexican, Mexican Am., Chicano

Does this person usually live or stay somewhere else?
For example – Read the examples to respondent.
Mark I
K all that apply.
J
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

For another reason

For a job or business

No

Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

In a nursing home

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

Stepson or stepdaughter
Brother or sister

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

R

Adopted son or daughter

T

Father or mother

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

AF

Opposite-sex husband/wife/spouse

Biological son or daughter

4.

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark I
K ONE box.
J

Other relative

Roommate or housemate

D

3.

7. Please read the RACE section on the Information Sheet.

Foster child

Other nonrelative

Is this person male or female? Mark I
K ONE box.
J
Male

Female

5. What was this person’s age on (Special Census Day)? What is
this person’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.
Age on (Special Census Day)

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print numbers in boxes.
Month
Day
Year of birth

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

years
Some other race – Print race or origin. C

➜ If more people were counted in Question S6 on the
front page, continue with Person 6 on the next page.

6

23013063

§8"?h¤
Person 6
1. What is Person 6’s name?

➜ NOTE: Please answer BOTH the question about Hispanic
origin and the question about race. For this census, Hispanic
origin is not a race.

Print name below and verify the spelling.
First Name

MI

6.
Last Name(s)

Please read the HISPANIC ORIGIN section on the Information
Sheet.
Is this person of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin

2.

Yes, Mexican, Mexican Am., Chicano

Does this person usually live or stay somewhere else?
For example – Read the examples to respondent.
Mark I
K all that apply.
J
With a parent or other relative

In a jail or prison

For college

At a seasonal or
second residence

For a military assignment

For another reason

For a job or business

No

Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Print, for
example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, etc. C

In a nursing home

Father or mother

Opposite-sex unmarried partner

Grandchild

Same-sex husband/wife/spouse

Parent-in-law

Same-sex unmarried partner

Son-in-law or daughter-in-law

4.

Black or African Am. – Print, for example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. C

Other relative

American Indian or Alaska Native – Print name of enrolled or
principal tribe(s), for example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, etc. C

Roommate or housemate

D

Adopted son or daughter

White – Print, for example, German, Irish, English, Italian,
Lebanese, Egyptian, etc. C

AF

Opposite-sex husband/wife/spouse

Biological son or daughter

What is this person’s race?
Mark I
K one or more boxes AND print origins.
J

T

Please read the RELATIONSHIP section on the Information
Sheet.
How is this person related to Person 1? Mark I
K ONE box.
J

R

3.

7. Please read the RACE section on the Information Sheet.

Stepson or stepdaughter

Foster child

Brother or sister

Other nonrelative

Is this person male or female? Mark I
K ONE box.
J
Male

Female

5. What was this person’s age on (Special Census Day)? What is
this person’s date of birth? If you don’t know the exact age,
please estimate. For babies less than 1 year old, do not report
the age in months. Report 0 as the age.
Age on (Special Census Day)

Chinese

Vietnamese

Native Hawaiian

Filipino

Korean

Samoan

Asian Indian

Japanese

Chamorro

Other Asian –
Print, for example,
Pakistani, Cambodian,
Hmong, etc. C

Print numbers in boxes.
Month
Day
Year of birth

Other Pacific Islander –
Print, for example,
Tongan, Fijian,
Marshallese, etc. C

years
Some other race – Print race or origin. C

➜ If more than 6 people were counted in Question S6,
continue with the next person on the Continuation
Questionnaire (SC -CQ), and update number of
continuation questionnaires on page 8.

7

23013071

§8"?z¤

OMB No. XXXX-XXXX

RESPONDENT INFORMATION

R1. What is your name? Print name below and verify the spelling. R2. What is your telephone number? We will only contact
First Name

you if needed for official Census Bureau business.

MI

Telephone
Number

–

–

R3. To confirm: Did you

Last Name(s)

Live or stay in this [house/apartment/mobile home]
on (Special Census Day)?
Move in to this [house/apartment/mobile home]
after (Special Census Day)?

Address of proxy

Not live or stay in this [house/apartment/mobile home]
(neighbor or other proxy)?

R4. Are there any other living quarters either occupied or
vacant at this address?
Yes ➜ List on SC-921, Add Page, if it is not listed on the SC-920,
Address List Page, and complete an unlabeled SC-Q
No

INTERVIEW SUMMARY

B.

Unit Status on (Special Census Day)
Occupied

Nonresidential

Vacant – regular

Empty mobile
home/trailer site

For rent

Vacant – usual
home elsewhere

Unable to locate

Rented, not
occupied

Uninhabitable

Cannot work

T

For migrant
workers

For sale only
Sold, not
occupied

For seasonal,
recreational or
occasional use

D

JIC1

Number of people
listed on questionnaire(s) =
01 – 99 = Total people
00 = Vacant

D. Language Code =
E. Interview Outcome Code

Other vacant

R

Duplicate – record Survivor ID below. C

C.

If vacant, ask: Which category best
describes this vacant unit as of
(Special Census Day)?

AF

A.

F.

UHE

RE

MOV

CO

REP

Are there any continuation
questionnaires for this address?
Yes ➜ Number of
continuation questionnaires =

JIC2

No

RECORD OF CONTACT

Type

Month

✗ In-Person

Day

Hour

/

Minute

Outcome

Type

a.m.

:

In-Person

p.m.
Month
In-Person

Day

Hour

/

Minute

Telephone
In-Person

Day

Hour

/

Telephone

OUTCOME CODES: NV = Left Notice of Visit

Minute

:

Minute
a.m.

:
Day

Hour

/

Minute

p.m.
Month

In-Person

p.m.

Telephone

RE = Refusal

Outcome
a.m.

:

Telephone

a.m.

Outcome

p.m.

In-Person

Outcome

NC = No Contact

Hour

/
Month

p.m.
Month

Day

Telephone
Outcome

a.m.

:

Month

Day

Hour

/

CI = Conducted Interview

Minute

Outcome
a.m.

:

p.m.

OT = Other

CERTIFICATION
I certify that the entries I have made on this questionnaire are true and correct to the best of my
knowledge.
Field Representative’s Signature

Month

Day

Employee ID

Year

8

23013089

Field Supervisor
Initials

FSA Number

Month

Year

Day