2019 Census Test: Collective Dwelling Record - Form 1A

  • Final outcome code

Preparations for the next Census of Population have begun, and Statistics Canada is seeking your participation in this important test. Census information is important for you and your community and is used to plan services that support employment, schools, public transportation and hospitals. By law, all residents living in facilities and establishments that were selected for the 2019 Census Test must be counted. All answers are collected under the authority of the Statistics Act and will be kept strictly confidential.

Confidential when completed

Section I - Identification

  • Survey Specific Identifier (SSID)
  • CLD
  • Block No.
  • Crew leader name
  • Name of collective dwelling
  • Address
  • Maximum occupancy
  • Collective dwelling type code
  • Total usual residents (URs)
  • Total temporary residents (TRs)
  • Total foreign residents (FRs)
  • Number of private dwellings attached
  • Contact name
  • Contact telephone number
  • Contact address
  • Contact email

Complete only if final outcome code is '324' (Cancelled)

  • Private dwelling
  • Business/establishment that does not provide overnight accommodation
  • Incorrect address
  • Demolished
  • Duplicate

Comments

Section II - Collective dwelling type code and auxiliary questions

Select one collective dwelling type and answer the corresponding questions.

Hospital (10)

A1) Is this facility licensed as a hospital?

  • Yes
  • No

A2) What services are provided at this facility? (Mark one only)

  • Short-term care
  • Long-term care
  • Both short-term and long-term care

Nursing home and/or residence for senior citizens (20)

B1) What levels of service are provided to residents at this facility? (Mark one only)

  • Extended health care services (professional health care monitoring, nursing care and supervision 24 hours a day). Residents are not independent in most activities of daily living.
  • Support services or assisted living services (meals, housekeeping, laundry, supervision of medication, assistance bathing or dressing, etc.), but no extended health care services. Residents are independent in most activities of daily living.
  • Extended health care services to some residents, but only support services or assisted living services to other residents. For example, a facility that is a mix of both a nursing home and a residence for senior citizens.

Note: If no care and service is provided to anyone, the facility should be enumerated as a private dwelling.

Residential care facility, such as a group home for persons with disabilities or addictions (30)

C1) Is this facility for (mark all that apply):

  • primarily children/minors
  • persons with physical challenges and/or disabilities
  • persons with psychological disabilities
  • persons that are developmentally delayed
  • persons with an addiction
  • other – specify:

Shelter (40)

D1) Is this facility primarily for (mark one only):

  • homeless persons
  • abused women and their children
  • ex-inmates (in halfway houses)
  • refugees and asylum seekers
  • other – specify:

Correctional or custodial facility (50)

E1) Is this facility primarily a (mark one only):

  • federal correctional facility
  • provincial/territorial custodial facility
  • young offenders' facility
  • jail/police lock-up facility

Lodging or rooming house (60)

Religious establishment such as a convent, monastery or seminary (70)

Establishment with temporary accommodation services such as a hotel, campground, YMCA/YWCA, Ronald McDonald House or hostel (90)

F1) Is this establishment a (mark one only):

  • hotel, motel or tourist establishment
  • campground or park
  • other establishment with temporary accommodation services such as a YMCA/YWCA, Ronald McDonald House or hostel

Other establishment such as a school residence, military base, work camp or vessel (91)

G1) Is this establishment a (mark one only):

  • school residence or training centre residence
  • commercial vessel
  • government vessel
  • military base
  • work camp
  • other

Section III - Occupancy May 13 / May 14

 
  Room or unit no Usually lives here ( X ) Unoccupied
( X )		 Name  of occupant
(If name not available, enter "X")		 Number of URs Number of TRs Number of FRs Remarks
1 2 3 4 5 6 7 8 9
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