Census of England and Wales, 1911
Before writing on this schedule please read the Examples and the Instructions given on the other side of the paper, as well as the headings of the Columns. The entries should be written in Ink.
The contents of the Schedule will be treated as confidential. Strict care will be taken that no information is disclosed with regard to individual persons. The returns are not to be used for proof of age, as in connection with Old Age Pensions, or for any other purpose than the preparation of Statistical Tables.
1. Name and Surname
of every Person, whether Member of Family, Visitor, Boarder, or Servant, who
2. Arrived in this dwelling on the morning of Monday, April 3rd, not having been enumerated elsewhere.
No one else must be included.
(For order of entering names see Examples on the back of the Schedule.)
2. Relationship to Head of Family
State whether 'Head', or 'Wife,' 'Son,' 'Daughter,' or other Relative, 'Visitor,' 'Boarder,' or 'Servant.'
Age (last birthday) and Sex
For Infants under one year state the age in months as 'under one month,' 'one month,' etc.
4. [ ] Age of females
Particulars as to Marriage
5. Write 'Single,' 'Married,' 'Widower,' or 'Widow,' opposite the names of all persons age 15 years and upwards.
State, for each Married Woman entered on the Schedule, the number of:
Children born alive to the present marriage. (If no children born alive write 'None' in Column 7.)
8. [ ] Children still living
9. [ ] Children who have Died
Profession or Occupation of Persons aged ten years and upwards
10. Personal Occupation.
If engaged in any Trade of Manufacture, the particular kind of work done and the Article made or Material worked or dealt in should be clearly indicated.
(See Instructions 1 to 8 and Examples on back of Schedule)
11. Industry or Service with which worker is connected.
No entry needed for Domestic Servants in private employment.
If employed by a public body (Government, Municipal, etc.) state what body.
(See Instruction 9 and Example on back of Schedule)
12. Whether Employer, Worker, or Working on Own Account.
 'Worker' (that is working for an employer), or
 'Own Account' (that is neither employing others nor working for a trade employer)
13. Whether Working at Home.
14. Birthplace of every person
 If born in any other part of the British Empire, write the name of the Dependency, Colony, etc., and of the Province or State
 If born in a Foreign Country, write the name the Country
 If born at sea, write 'At Sea'
 'Naturalized British subject', giving year of naturalization
 If of foreign nationality, state whether 'French', 'German', 'Russian', etc.
If any person included to this Schedule is:
 ' Totally Blind'
 'Imbecile' or 'Feeble-minded'
state the infirmity opposite that person's name, and the age at which she or he became afflicted.