OMB No.

xxxx-xxxx: Approval Expires xx/xx/xxxx

U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration

2018 Census Test U.S. CENSUS BUREAU

FOR
OFFICIAL
USE ONLY

T
AF

Start here OR go online at survey.census.gov to complete the 2018 Census Test.

Use a blue or black pen.
2. Were there any additional people staying here on April 1, 2018
R

that you did not include in Question 1?

Before you answer Question 1, count the people living in this Mark I
J
K all that apply.
house, apartment, or mobile home using our guidelines.
Children, related or unrelated, such as newborn babies,
• Count all people, including babies, who live and sleep here grandchildren, or foster children
D

most of the time.

Relatives, such as adult children, cousins, or in-laws
• If no one lives and sleeps at this address most of the time, go
online at survey.census.gov or call the number on page 8. Nonrelatives, such as roommates or live-in babysitters
People staying here temporarily
The census must also include people without a permanent
No additional people
place to live, so:
• If someone who does not have a permanent place to live is 3. Is this house, apartment, or mobile home — Mark K
J ONE box.
I
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staying here on April 1, 2018, count that person.

Owned by you or someone in this household with a mortgage
The Census Bureau also conducts counts in institutions and or loan? Include home equity loans.
other places, so: Owned by you or someone in this household free and clear
11528015

(without a mortgage or loan)?

• Do not count anyone living away from here, either at college
or in the Armed Forces. Rented?
• Do not count anyone in a nursing home, jail, prison, detention Occupied without payment of rent?
facility, etc., on April 1, 2018.
• Leave these people off your questionnaire, even if they will 4. What is your telephone number?
return to live here after they leave college, the nursing home, We will only contact you if needed for official Census Bureau
the military, jail, etc. Otherwise, they may be counted twice. business.
Telephone Number
1. How many people were living or staying in this house,
apartment, or mobile home on April 1, 2018? – –

Number of people =
FORM DH-1 (05-16-2017) Draft 9
 Person 1 8. What is Person 1’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
Note, you may report more than one group.
5. Please provide information for each person living here. If
there is someone living here who pays the rent or owns this WHITE – Provide details below.
residence, start by listing him or her as Person 1. If the
owner or the person who pays the rent does not live here, German Irish English
start by listing any adult living here as Person 1. Italian Polish French
What is Person 1’s name? Print name below. Print, for example, Scottish, Norwegian, Dutch, etc.
First Name MI

HISPANIC, LATINO, OR SPANISH – Provide details below.

Last Name(s) Mexican Puerto
or Mexican Rican Cuban
American
Salvadoran Dominican Colombian
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.

6. What is Person 1’s sex? Mark K

J ONE box.
I

Male Female BLACK OR AFRICAN AMERICAN – Provide details below.

African Jamaican Haitian
American
7. What is Person 1’s age and what is Person 1’s date of Nigerian Ethiopian Somali
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes.
T Print, for example, Ghanaian, South African, Barbadian, etc.

Age on April 1, 2018 Month Day Year of birth

ASIAN – Provide details below.
AF
years Chinese Filipino Asian Indian
Vietnamese Korean Japanese
Print, for example, Pakistani, Cambodian, Hmong, etc.

AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,

R

Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of

Barrow Inupiat Traditional Government, Tlingit, etc.
D

MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Print, for example, Algerian, Iraqi, Kurdish, etc.
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NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide

details below.
11528023

Native Samoan Chamorro

Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.

SOME OTHER RACE OR ETHNICITY – Print details.

➜ If more people were counted in Question 1 on

the front page, continue with Person 2 on the
next page.

2
 1. Print name of Person 2 6. What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
First Name MI Note, you may report more than one group.

WHITE – Provide details below.

Last Name(s) German Irish English

Italian Polish French
Print, for example, Scottish, Norwegian, Dutch, etc.

2. Does this person usually live or stay somewhere else?

Mark K
J all that apply.
I HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican Puerto
No or Mexican Cuban
American Rican
Yes, with a parent or Salvadoran Dominican Colombian
Yes, for college other relative
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.
Yes, for a military assignment Yes, at a seasonal or
second residence
Yes, for a job or business Yes, in a jail or prison
Yes, in a nursing home Yes, for another reason BLACK OR AFRICAN AMERICAN – Provide details below.
African Jamaican Haitian
American
3. How is this person related to Person 1? Mark K
J ONE box.
I Nigerian Ethiopian Somali
Opposite-sex husband/wife/spouse

Opposite-sex unmarried partner

T Print, for example, Ghanaian, South African, Barbadian, etc.

Same-sex husband/wife/spouse
ASIAN – Provide details below.
AF
Same-sex unmarried partner
Chinese Filipino Asian Indian
Biological son or daughter Vietnamese Korean Japanese
Adopted son or daughter Print, for example, Pakistani, Cambodian, Hmong, etc.

Stepson or stepdaughter

Brother or sister
AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
R

Father or mother Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.
Grandchild

Parent-in-law
D

Son-in-law or daughter-in-law MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Other relative Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Roommate or housemate
Print, for example, Algerian, Iraqi, Kurdish, etc.
Foster child
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Other nonrelative
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
4. What is this person’s sex? Mark K
J ONE box.
I
11528031

Native Samoan Chamorro

Male Female Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.
5. What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes. SOME OTHER RACE OR ETHNICITY – Print details.
Age on April 1, 2018 Month Day Year of birth

years
➜ If more people were counted in Question 1 on
the front page, continue with Person 3 on the
next page.
3
 1. Print name of Person 3 6. What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
First Name MI Note, you may report more than one group.

WHITE – Provide details below.

Last Name(s) German Irish English

Italian Polish French
Print, for example, Scottish, Norwegian, Dutch, etc.

2. Does this person usually live or stay somewhere else?

Mark K
J all that apply.
I HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican Puerto
No or Mexican Cuban
American Rican
Yes, with a parent or Salvadoran Dominican Colombian
Yes, for college other relative
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.
Yes, for a military assignment Yes, at a seasonal or
second residence
Yes, for a job or business Yes, in a jail or prison
Yes, in a nursing home Yes, for another reason BLACK OR AFRICAN AMERICAN – Provide details below.
African Jamaican Haitian
American
3. How is this person related to Person 1? Mark K
J ONE box.
I Nigerian Ethiopian Somali
Opposite-sex husband/wife/spouse

Opposite-sex unmarried partner

T Print, for example, Ghanaian, South African, Barbadian, etc.

Same-sex husband/wife/spouse
ASIAN – Provide details below.
AF
Same-sex unmarried partner
Chinese Filipino Asian Indian
Biological son or daughter Vietnamese Korean Japanese
Adopted son or daughter Print, for example, Pakistani, Cambodian, Hmong, etc.

Stepson or stepdaughter

Brother or sister
AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
R

Father or mother Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.
Grandchild

Parent-in-law
D

Son-in-law or daughter-in-law MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Other relative Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Roommate or housemate
Print, for example, Algerian, Iraqi, Kurdish, etc.
Foster child
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Other nonrelative
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
4. What is this person’s sex? Mark K
J ONE box.
I
11528049

Native Samoan Chamorro

Male Female Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.
5. What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes. SOME OTHER RACE OR ETHNICITY – Print details.
Age on April 1, 2018 Month Day Year of birth

years
➜ If more people were counted in Question 1 on
the front page, continue with Person 4 on the
next page.
4
 1. Print name of Person 4 6. What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
First Name MI Note, you may report more than one group.

WHITE – Provide details below.

Last Name(s) German Irish English

Italian Polish French
Print, for example, Scottish, Norwegian, Dutch, etc.

2. Does this person usually live or stay somewhere else?

Mark K
J all that apply.
I HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican Puerto
No or Mexican Cuban
American Rican
Yes, with a parent or Salvadoran Dominican Colombian
Yes, for college other relative
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.
Yes, for a military assignment Yes, at a seasonal or
second residence
Yes, for a job or business Yes, in a jail or prison
Yes, in a nursing home Yes, for another reason BLACK OR AFRICAN AMERICAN – Provide details below.
African Jamaican Haitian
American
3. How is this person related to Person 1? Mark K
J ONE box.
I Nigerian Ethiopian Somali
Opposite-sex husband/wife/spouse

Opposite-sex unmarried partner

T Print, for example, Ghanaian, South African, Barbadian, etc.

Same-sex husband/wife/spouse
ASIAN – Provide details below.
AF
Same-sex unmarried partner
Chinese Filipino Asian Indian
Biological son or daughter Vietnamese Korean Japanese
Adopted son or daughter Print, for example, Pakistani, Cambodian, Hmong, etc.

Stepson or stepdaughter

Brother or sister
AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
R

Father or mother Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.
Grandchild

Parent-in-law
D

Son-in-law or daughter-in-law MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Other relative Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Roommate or housemate
Print, for example, Algerian, Iraqi, Kurdish, etc.
Foster child
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Other nonrelative
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
4. What is this person’s sex? Mark K
J ONE box.
I
11528056

Native Samoan Chamorro

Male Female Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.
5. What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes. SOME OTHER RACE OR ETHNICITY – Print details.
Age on April 1, 2018 Month Day Year of birth

years
➜ If more people were counted in Question 1 on
the front page, continue with Person 5 on the
next page.
5
 1. Print name of Person 5 6. What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
First Name MI Note, you may report more than one group.

WHITE – Provide details below.

Last Name(s) German Irish English

Italian Polish French
Print, for example, Scottish, Norwegian, Dutch, etc.

2. Does this person usually live or stay somewhere else?

Mark K
J all that apply.
I HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican Puerto
No or Mexican Cuban
American Rican
Yes, with a parent or Salvadoran Dominican Colombian
Yes, for college other relative
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.
Yes, for a military assignment Yes, at a seasonal or
second residence
Yes, for a job or business Yes, in a jail or prison
Yes, in a nursing home Yes, for another reason BLACK OR AFRICAN AMERICAN – Provide details below.
African Jamaican Haitian
American
3. How is this person related to Person 1? Mark K
J ONE box.
I Nigerian Ethiopian Somali
Opposite-sex husband/wife/spouse

Opposite-sex unmarried partner

T Print, for example, Ghanaian, South African, Barbadian, etc.

Same-sex husband/wife/spouse
ASIAN – Provide details below.
AF
Same-sex unmarried partner
Chinese Filipino Asian Indian
Biological son or daughter Vietnamese Korean Japanese
Adopted son or daughter Print, for example, Pakistani, Cambodian, Hmong, etc.

Stepson or stepdaughter

Brother or sister
AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
R

Father or mother Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.
Grandchild

Parent-in-law
D

Son-in-law or daughter-in-law MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Other relative Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Roommate or housemate
Print, for example, Algerian, Iraqi, Kurdish, etc.
Foster child
§,Uqa¤

Other nonrelative
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
4. What is this person’s sex? Mark K
J ONE box.
I
11528064

Native Samoan Chamorro

Male Female Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.
5. What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes. SOME OTHER RACE OR ETHNICITY – Print details.
Age on April 1, 2018 Month Day Year of birth

years
➜ If more people were counted in Question 1 on
the front page, continue with Person 6 on the
next page.
6
 1. Print name of Person 6 6. What is this person’s race or ethnicity?
Mark all boxes that apply AND print ethnicities in the spaces below.
First Name MI Note, you may report more than one group.

WHITE – Provide details below.

Last Name(s) German Irish English

Italian Polish French
Print, for example, Scottish, Norwegian, Dutch, etc.

2. Does this person usually live or stay somewhere else?

Mark K
J all that apply.
I HISPANIC, LATINO, OR SPANISH – Provide details below.
Mexican Puerto
No or Mexican Cuban
American Rican
Yes, with a parent or Salvadoran Dominican Colombian
Yes, for college other relative
Print, for example, Guatemalan, Spaniard, Ecuadorian, etc.
Yes, for a military assignment Yes, at a seasonal or
second residence
Yes, for a job or business Yes, in a jail or prison
Yes, in a nursing home Yes, for another reason BLACK OR AFRICAN AMERICAN – Provide details below.
African Jamaican Haitian
American
3. How is this person related to Person 1? Mark K
J ONE box.
I Nigerian Ethiopian Somali
Opposite-sex husband/wife/spouse

Opposite-sex unmarried partner

T Print, for example, Ghanaian, South African, Barbadian, etc.

Same-sex husband/wife/spouse
ASIAN – Provide details below.
AF
Same-sex unmarried partner
Chinese Filipino Asian Indian
Biological son or daughter Vietnamese Korean Japanese
Adopted son or daughter Print, for example, Pakistani, Cambodian, Hmong, etc.

Stepson or stepdaughter

Brother or sister
AMERICAN INDIAN OR ALASKA NATIVE – Print, for example,
R

Father or mother Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Traditional Government, Tlingit, etc.
Grandchild

Parent-in-law
D

Son-in-law or daughter-in-law MIDDLE EASTERN OR NORTH AFRICAN – Provide details below.

Other relative Lebanese Iranian Egyptian

Syrian Moroccan Israeli
Roommate or housemate
Print, for example, Algerian, Iraqi, Kurdish, etc.
Foster child
§,Uqi¤

Other nonrelative
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – Provide
details below.
4. What is this person’s sex? Mark K
J ONE box.
I
11528072

Native Samoan Chamorro

Male Female Hawaiian
Tongan Fijian Marshallese
Print, for example, Palauan, Tahitian, Chuukese, etc.
5. What is this person’s age and what is this person’s date of
birth? For babies less than 1 year old, do not write the age in
months. Write 0 as the age.
Print numbers in boxes. SOME OTHER RACE OR ETHNICITY – Print details.
Age on April 1, 2018 Month Day Year of birth

years
➜ If more people were counted in Question 1 on
the front page, continue with Person 7 on the
next page.
7
 OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

Use this section to complete information for the rest of the people you counted in Question 1 on the front page.
We may call for additional information about them.

Person 7
First Name MI Last Name(s)

Date of Birth
Sex Age on April 1, 2018 Month Day Year of birth Related to Person 1?

Male Female years Yes No

Person 8
First Name MI Last Name(s)

Date of Birth
Sex Age on April 1, 2018 Month Day Year of birth Related to Person 1?

Male Female years Yes No

Person 9
T
First Name MI Last Name(s)
AF
Date of Birth
Sex Age on April 1, 2018 Month Day Year of birth Related to Person 1?

Male Female years Yes No

Person 10
R

First Name MI Last Name(s)

D

Date of Birth
Sex Age on April 1, 2018 Month Day Year of birth Related to Person 1?

Male Female years Yes No

FOR OFFICIAL USE ONLY

JIC1 JIC2
Thank you for completing the 2018 Census Test.
§,Uqq¤

11528080

If your enclosed postage-paid envelope is missing, U.S. Census Bureau

please mail your completed questionnaire to: National Processing Center
1201 East 10th Street
Jeffersonville, IN 47132

If you need help completing this questionnaire, call 1-844-330-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET. The telephone
call is free.
TDD — Telephone display device for the hearing impaired. Call 1-844-467-2020, Sunday through Saturday from 7:00 a.m. to 12:00 a.m. ET.
The telephone call is free.

The U.S. Census Bureau estimates that completing the questionnaire will take 10 minutes on average. Send comments regarding this burden estimate or any other aspect
of this burden to: Paperwork Reduction Project xxxx-xxxx, U.S. Census Bureau, DCMD-2H174, 4600 Silver Hill Road, Washington, DC 20233. You may email comments
to <2020.census.paperwork@census.gov>; use “Paperwork Reduction Project xxxx-xxxx” as the subject.
This collection of information has been approved by the Office of Management and Budget (OMB). The eight-digit approval number that appears at the upper right of the
questionnaire confirms this approval. If this number were not displayed, we could not conduct this survey.