You Have a Right to Question the Census Worker

You can download and print out this Public Servant Questionnaire PDF and keep it handy by your door, when the census worker knocks on your door hand the questionnaire to him or her. Be sure you have two witnesses when the census worker fills this out as the signatures of two witnesses are required. It is highly unlikely however, that the census worker is going to fill out your Public Servant Questionnaire. I suppose then, if you chose to, that it would be possible to say, “Turnabout is fair play, I guess I won’t be filling out your questionnaire either.”

The instructions for the public servant (in this case the census worker) are printed on the first page and are as follows:

 “Public Law 93-579 states in part: “The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy by requiring Federal agencies to permit an individual to determine what records pertaining to him are collected, maintained, used, or disseminated by such agencies.” The following questions are based upon that act and are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency.

Fill out the form completely. If any question does not apply, mark the answer with N/A or Not applicable. Do not leave any question blank.”

There are 23 questions on the Public Servant Questionnaire.

Public Servant Information
1. Full Legal Name:
__________________________________________________________
2. Residence Address
__________________________________________________________
City __________________________State _______ Zip ______________
Department Information:
3. Name of department, bureau, or agency by which public servant is employed:
__________________________________________________________
City __________________________State _______ Zip ______________
Supervisor’s name:
__________________________________________________________
4. Mailing address
__________________________________________________________
City __________________________State _______ Zip ______________
Public Servant Duty
5. Will public servant uphold the Constitution of the United States?
__________________________________________________________
6. Did public servant furnish proof of identity?
__________________________________________________________
7. What was the nature of proof?
__________________________________________________________
8. Will public servant furnish a copy of the law or regulation which authorizes this investigation?
__________________________________________________________
9. Will the public servant read aloud the portion of the law authorizing the questions he will ask?
__________________________________________________________
Nature of Investigation
10. Are the answers to the questions voluntary or mandatory?
__________________________________________________________
11. Are the questions to be asked based upon a specific law/regulation, or are they being used as a discovery process?
__________________________________________________________
12. What other uses may be made of this information?
__________________________________________________________
13. What other agencies may have access to this information?
__________________________________________________________
__________________________________________________________
14. What will be the effect upon me if I should choose not to answer any part or all of these questions?
__________________________________________________________
__________________________________________________________
__________________________________________________________
Basis for Investigation
15. Name of person in government requesting that this investigation be made.
__________________________________________________________
16. Is this investigation ‘general’ or is it ‘special’?
__________________________________________________________
17. Have you consulted, questioned, interviewed, or received information from any third party relative to this investigation?
__________________________________________________________
18. If so, the identity of such third parties:
__________________________________________________________
__________________________________________________________
__________________________________________________________
Expected Results of Investigation:
19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the requested information?
__________________________________________________________
Agency Information
20. Is there a file of records, information, or correspondence relating to me being maintained by this agency? ______________ If yes, which?
__________________________________________________________
__________________________________________________________
__________________________________________________________
21. Is this agency using any information pertaining to me which was supplied by another agency or government source?
__________________________________________________________
__________________________________________________________
22. May I have a copy of that information? ______________ If not, why not?
__________________________________________________________
__________________________________________________________
If so, how may I obtain a copy of that information?
__________________________________________________________
__________________________________________________________
23. Will the public servant guarantee that the information in these files will not be used by any department other than the one by whom he is employed? __________
If not, why not?
__________________________________________________________
__________________________________________________________

The questions are followed by an affirmation.

Affirmation:

If any request for information relating to me is received from any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by the act.

I swear (affirm) that the answers I have given to the foregoing questions are complete and correct in every particular.

Print name: ___________________________________________________

Signature: ___________________________________________________

Date: ________(month)_________(day)___________________(year)

First Witness Printed Name: ________________________________________

First Witness Signature: ________________________________________

Second Witness Printed Name: ______________________________________

Second Witness Signature: ________________________________________

The affirmation is followed by citations for Authorities for Questions:

Authorities for Questions:

Questions 1,2,3,4:  In order to be sure you know exactly who you are giving the information to. Residence and business addresses are needed in case you need to serve process in a civil or criminal action upon this individual.

Question5:  All public servants have taken a sworn oath to uphold and defend the constitution.

Questions 6-7:  This is standard procedure by government agents and officers. See Internal Revenue Manual, MT-9900-26, Section 242.133.

Questions 8,9,10: Title 5 USC 552a, paragraph (e) (3) (A)

Question 11: Title 5 USC 552a, paragraph (d) (5), (e) (1)

Questions 12,13: Title 5 USC 552a, paragraph (e) (3) (B), (e) (3) (C)

Question 14: Title 5 USC 552a, paragraph (e) (3) (D)

Question 15: Public Law 93-579 (b) (1)

Question 16: Title 5 USC 552a, paragraph (e) (3) (A)

Questions 17-18: Title 5 USC 552a, paragraph (e) (2)

Question 19: Title 5 USC 552a, paragraph (d) (5)

Questions 20-21: Public Law 93-579 (b) (1)

Question 22: Title 5 USC 552a, paragraph (d) (1)

Question 23: Title 5 USC 552a, paragraph (e) (1 

So there you have it, a questionnaire for the census worker.

Sign me,

Resident Apt. 1