Questionnaire Text

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4. Is this person --
Fill one circle.

[] White
[] Black or Negro
[] Japanese
[] Chinese
[] Filipino
[] Korean
[] Vietnamese
[] Asian Indian
[] Hawaiian
[] Guamanian
[] Samoan
[] Eskimo
[] Aleut
[] Other

____ Specify

[] Indian (Amer.)

____ Print tribe


[Fill the circle for the category with which the person most closely identifies. If you fill the Indian (American) or other circle, be sure to print the name of the specific Indian tribe or specific group.]