Census Problem Report Form

All Information is Confidential

Your Name
Phone
Address
Ethnicity
Native Language

Date of Incident
Time of Incident
Place of Incident
Address Where Incident Occurred

Census Questionnaire Forms Please check all that apply

Did not receive census questionnaire form
Census forms were not available in my language/dialect
Translated forms were delivered very late
Translation was poor
Need a blank form

Census Taker
What was the census taker’s name?
Did not speak my language/dialect
Which language/dialect did the census taker speak?
Had no identification or did not show it
Encouraged certain types of responses for specific questions
Which questions?

What did the census taker ask you to do?
Was rude or culturally insensitive
Please explain
Did not want to participate in census or did not want to open door to census taker
Please explain

Language Assistance Access Please check all that apply

Did not know language assistance was available

Problems with Telephone Questionnaire Assistance (TQA):
Did not offer my language
Gave wrong or poor information
Other

Problems with Questionnaire Assistance Center (QAC):
No translated form
Did not offer language
Hours of operation were inconvenient
Location was inconvenient
Other

Details: