Questionnaire Text

Questionnaire form view entire document:  text  image

Note: Please answer both Questions 5 and 6.
5. Is this person Spanish/Hispanic/Latino?
Mark [X] the "No" box if not Spanish/Hispanic/Latino
[] No, not Spanish/Hispanic/Latino
[] Yes, Mexican, Mexican American, Chicano
[] Yes, Puerto Rican
[] Yes, Cuban
[] Yes, other Spanish/Hispanic/Latino. Print group ____


6. What is this person's race?
Mark (X) one or more races to indicate what this person considers himself/herself to be
[] White
[] Black or African American
[] American Indian or Alaska Native -- Print the name of enrolled or principal tribe: _______
[] Asian Indian
[] Chinese
[] Filipino
[] Japanese
[] Korean
[] Vietnamese
[] Other Asian -- Print race _______
[] Native Hawaiian
[] Guamanian or Chamorro
[] Samoan
[] Other Pacific Islander -- Print race below _______
[] Some other race -- Print race below _______
Questionnaire instructions view entire document:  text  image

5. A person is of Spanish/Hispanic/Latino origin if the person's origin (ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban, Argentinean, Colombian, Costa Rican, Dominican, Ecuadoran, Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other Spanish-speaking countries of the Caribbean or Central or South America, or from Spain.
The term Mexican American refers to persons of Mexican origin or ancestry.
 
If you mark the "Yes, other Spanish/Hispanic/Latino" box, print the name of the specific group.
 
If a person is not of Spanish/Hispanic/Latino origin, answer this question by marking the "No, not Spanish/Hispanic/Latino" box.
This question should be answered for ALL persons, regardless of citizenship status.
6. Mark one or more categories to indicate [the ethnicity] each person considers himself or herself to be.
 If you mark the "American Indian or Alaska Native" box, also print the name of the tribe(s) in which the person is enrolled. If the person is not enrolled in a tribe, print the name of the principal tribe.
 
If you mark the "Other Asian" or the "Other Pacific Islander" box, print the name of the specific race(s) or group(s) in the space provided.
 
The category Other Asian includes persons who identify themselves as Burmese, Hmong, Indonesian, Laotian, Pakistani, Thai, Cambodian, Sri Lankan, and so on.
 
The category Other Pacific Islander includes persons who identify themselves as Fijian, Tongan, Polynesian, Tahitian, and so on.
 
If you mark the "Some other race" box, print the race(s) or group(s) in the space provided.
 
This question should be answered for ALL persons, regardless of citizenship status.