Census Problem Report Form - Asian American Legal Defense printable pdf download

Census Problem Report Form - Asian American Legal Defense

ASIAN AMERICAN LEGAL DEFENSE AND EDUCATION FUND

99 HUDSON STREET, 12

FL • NEW YORK, NY 10013 • TEL 212.966.5932 • •

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: __________________________________________________________________

Please check all that apply!

Census Questionnaire Forms

Language Assistance

[] Did not receive census form

[] Did not know language assistance was available

[] Census forms not in my language/dialect

Problems with Telephone Questionnaire Assistance (TQA):

[] Forms delivered late

[] Did not offer my language

[] Translation was poor

[] Gave wrong or poor information

[] Need a blank form

[] Other: ______________________________________

Census Taker

Problems with Questionnaire Assistance Center (QAC):

What was the census taker’s name?

[] No translated form

_____________________________________________

[] Did not offer my language

[] Did not speak my language/dialect

•

[] Hours of operation were inconvenient

Which language/dialect did the census taker speak?

[] Location was inconvenient

________________________________________

[] Other: _____________________________________

[] 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 below)

[] Did not want to participate in census or did not want to open door to census taker (Please explain below)

Details (continue on the back of the page if more space is needed)

Return to: Julia Yang, AALDEF Census Coordinator,

99 Hudson Street, 12th Floor; New York, NY 10013; FAX 212/966-4303

Census Problem Report Form - Asian American Legal Defense

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