Completing the 2010 Census Questionnaire: Easy and Confidential:
* EASY - The 2010 Census questionnaire asks only a few simple questions of each person -- name, relationship, gender, age and date of birth, race and whether the respondent owns or rents his or her home. This simple, short questionnaire takes just a few minutes to complete and return by mail. The questions and responses are as follows:
1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2010? Number of people = _____
2. Were there any additional people staying here April 1, 2010 that you did not include in Question 1? Mark X all that apply.
--- Children, such as newborn babies or foster children
--- Relatives, such as adult children, cousins, or in-laws
--- Nonrelatives, such as roommates or live-in baby sitters
--- People staying here temporarily
--- No additional people
3. Is this house, apartment, or mobile home ___ Mark X ONE box.
--- Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
--- Owned by you or someone in this household free and clear (without a mortgage or loan)?
--- Rented?
--- Occupied without payment or rent?
4. What is your telephone number? We may call if we don't unerstand an answer.
--- Area Code + Number ____________________
5. Please provide information for each person living here. Start with a person living here who owns or rents this house, apartment
or mobile home. If the owner or renter lives somewhere else, start with anyone living here. This will be Person 1.
What is Person 1's name? Print name below:
--- Last Name
--- First Name --- MI
6. What is Person 1's sex? Mark X ONE box.
--- Male --- Female
7. What is Person 1's age and what is Person 1's date of birth?
Please report babies as age 0 when the child is less than 1 year old. Print numbers in boxes.
--- Age on April 1, 2010 Month, Day, Year of birth
--> NOTE: Please answer BOTH Question 8 about Hispanis origin and Question 9 about race. For this census, Hispanic origins are
not race.
8. Is Person 1 of Hispanic, Latino, or Spanish origin?
--- No, not of Hispanic, Latino, or Spanish origin
--- Yes, Mexican, Mexican Am., Chicano
--- Yes, Puerto Rican
--- Yes, Cuban
--- Yes, another Hispanis, Latino, or Spanish origin --- Print origin, for example Argentinian, Colombian, Domincan, Nicaraguan, and so on.
9. What is Person 1's race? Mark X one or more boxes.
--- White
--- Black, African Am.n or Negro
--- American Indian or Alaska Native
--- Asian Indian --- Japanese --- Native Hawaiian
--- Chinese --- Korean --- Guamanian or Chamorro
--- FILIPINO --- Vietnamese --- Samoan
--- Other Asian --- Print race, for --- Other Pacific Islander -- Print race, for example, Fijian,
example, Hmong, Laotian, Thai, and so on.
Pakistani, Cambodian, and so on
--- Some other race --- Print race
* For Question #9 (What is Person 1's Race?) be sure to check ONLY "FILIPINO"
.
10. Does Person 1 sometimes live or stay somewhere else?
--- No --- Yes -- Mark X all that apply.
-- In college housing -- For child custody
-- In the military -- In jail or prison
-- At a seasonal or second -- In a nursing home
residence -- For another reason
--- > If more people were counted in Question 1, continue with Person 2, and so on.
* CONFIDENTIAL AND SAFE - The Census Bureau does NOT release or share information that identifies individual respondents or their households for 72 years. Not even the President, Congress, the FBI, the Customs and Immigration Service or the courts can have access to your responses to the Census Questionnaire.