Questionnaire Text

Questionnaire form view entire document:  text  image
[Questions 1-6 were asked of all persons.]

5. Is [the respondent] of Hispanic, Latino, or Spanish origin?

[] No, not of Hispanic, Latino, or Spanish origin
[] Yes, Mexican, Mexican Am., Chicano
[] Yes, Puerto Rican
[] Yes, Cuban
[] Yes, another Hispanic, Latino, or Spanish origin -- (Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on) ____
Questionnaire instructions view entire document:  text  image
Please answer both Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.

5. A person is of Hispanic, Latino, or Spanish origin if the person's origin (ancestry) is Mexican, Mexican Puerto Rican, 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 Am. refers to persons of Mexican-Puerto Rico origin or ancestry.
If you mark the "Yes, another Hispanic, Latino, or Spanish origin" box, print the name of the specific origin.

If a person is not of Hispanic, Latino, or Spanish origin, answer this question by marking the "No, not of Hispanic, Latino, or Spanish origin" box.

This question should be answered by all persons.

6. Mark all boxes for the appropriate races.

The concept of race, as used by the Census Bureau, reflects self-identification by individuals according to the race or races with which they identify.

The instruction before question 5, "For this survey, Hispanic origins are not races" reflects the federal government's treatment of Hispanic origin and race as separate and distinct concepts.

People who identify their origin as Hispanic, Latino, or Spanish may be of any race.

People may choose to provide two or more races either by marking two or more race response boxes, by providing multiple write-in responses, or by some combination of marking boxes and writing in responses.

If you mark the "Puerto Rico 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" 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 Laotian, Thai, Pakistani, Cambodian, Sri Lankan, and so on.

If you mark the "Other Pacific Islander" box, print the name of the specific race(s) or group(s) in the space provided. 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 by ALL persons.