Household Census Questionnaire

Household Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Name of Head of Household

First NameLast Name

Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Total Number of People Living in Household

Type of Housing

Do you own or rent your home?

Please list each household member's details

Does your household have access to the following amenities? (Select all that apply)

How many rooms are in your household (excluding bathrooms and kitchen)?

What is the primary source of income for your household?

Please provide any additional comments or information about your household (optional)