Census 2011 - 3A

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For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.



The census is designed to provide information about the demographic and social characteristics of the people living in Canada and the housing/dwelling units they occupy.


This information is collected under the authority of the Statistics Act, R.S.C. 1985, c. S-19, and must be provided by law.

Confidential when completed



The confidentiality of your census responses is protected by law. All Statistics Canada employees have taken an oath of secrecy. Your personal census information cannot be given to anyone outside Statistics Canada without your consent. This is your right.

Your census information will be retained in accordance with legislative requirements and will be stored securely. You can ask to see the information about yourself on your 2011 Census questionnaire after November 2011. To do this, write the Privacy Coordinator, Statistics Canada, 25th Floor, R.H. Coats Building, Ottawa, Ontario K1A 0T6.


Steps A and B, and Question 1 are asked to determine who should complete this questionnaire. Questions 2 to 6 are asked to learn about the living arrangements of people living in Canada. This information is used for planning social programs, such as Old Age Security and the Canada Child Tax Benefit. It is also used by towns and cities to plan a variety of services such as day care centres, schools, police and fire protection. Questions 7, 8 and 9 provide information to determine the need for language services in English and French according to the Official Languages Act, and are used to implement programs that protect the rights of Canadians under the Canadian Charter of Rights and Freedoms. Question 10 provides each person with the opportunity to make an informed decision about what happens to his or her personal census information in 92 years.



- www.census2011.gc.ca
- Call us free of charge 1-877-777-2011
- TTY users call 1-866-753-7083

Ce questionnaire est disponible en français 1-877-777-2011

Introduction statement

Message from the Chief Statistician of Canada

The census has always provided a portrait of our people and the communities in which we live. The 2011 Census will continue this tradition.

Please answer the questions and follow the instructions on the envelope. If you want to complete the questionnaire online, please phone the Census Help Line at 1-877-777-2011 between 8 a.m. and 8 p.m. and ask for a secure access code.

By law, every person must complete a census questionnaire. By the same law, your responses will be kept confidential.Census information is important for your community and is vital for planning services such as schools, daycare, police services and fire protection.

Your information may be used by Statistics Canada in support of our other surveys or for analysis.

Thank you for your cooperation.

Reporting instructions

Complete the questionnaire:

- Please print using CAPITAL LETTERS.
- Mark circles with an "X".


STEP A - Question identifier:1.

Print your telephone number:

  • 1: Area Code, Telephone Number, Extension

STEP A - Question identifier:2.

Print the address where you received this questionnaire.

  • 1: No. and street or lot and concession
  • 2: Apt. no
  • 3: City, municipality, town, village, Indian reserve
  • 4: Province/territory
  • 5: Postal code


What is your name?

  • 1: Family Name, Given Name


Continue with Step D, if you are:

- a Canadian citizen
- a permanent resident (landed immigrant)
- a person from another country with a work or study permit
- in Canada asking for refugee status (refugee claimant)

Mark the circle and STOP HERE, if you are:

- a government representative of another country
- a resident of another country visiting Canada, for example, on vacation or on a business trip


Is this your main residence?

  • 1: Yes. Continue with Question 1(a).
  • 2: No, but I have no other residence in Canada. Continue with Question 1(a).
  • 3: No, it is somewhere else in Canada. Specify complete address.

STEP D - Question identifier:1.

(a) Is there any other address in Canada where someone may include you on the census form for that household?

  • 1: No. Go to Question 2.
  • 2: Yes. Specify complete address.

(b) Please give the name of another adult (if any) living at this other address.

  • 1: Family Name, Given Name

STEP D - Question identifier:2.

What is your sex?

  • 1: Male
  • 2: Female

STEP D - Question identifier:3.

What is your date of birth and your age?

  • 1: Day, Month, Year
  • 2: Age

STEP D - Question identifier:4.

What is your marital status?

  • 1: Never legally married
  • 2: Legally married (and not separated)
  • 3: Separated, but still legally married
  • 4: Divorced
  • 5: Widowed

STEP D - Question identifier:5.

Are you living with a common-law partner?

  • 1: Yes
  • 2: No

STEP D - Question identifier:6.

What is your status here (at the address you entered in STEP A)?

  • 1: Resident under care or custody (e.g., patient, inmate)
  • 2: Room-mate, lodger or boarder
  • 3: Employee
  • 4: Employee's family member
  • 5: Other - Specify

STEP D - Question identifier:7.

Can you speak English or French well enough to conduct a conversation?

  • 1: English only
  • 2: French only
  • 3: Both English and French
  • 4: Neither English nor French

STEP D - Question identifier:8.

(a) What language do you speak most often at home?

  • 1: English
  • 2: French
  • 3: Other - Specify

(b) Do you speak any other languages on a regular basis at home?

  • 1: No
  • 2: Yes, English
  • 3: Yes, French
  • 4: Yes, Other - Specify

STEP D - Question identifier:9.

What is the language that you first learned at home in childhood and still understand

  • 1: English
  • 2: French
  • 3: Other - Specify

STEP D - Question identifier:10.

Do you agree to make your 2011 Census information available in 2103 (92 years after the census)?

  • 1: Yes
  • 2: No
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