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 Am., 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
[] Asian Indian
[] Native Hawaiian
[] Black or African American
[] Chinese
[] Guamanian or Chamorro
[] American Indian or Alaska Native Print name of enrolled or principal tribe: _______
[] Filipino
[] Samoan
[] Japanese
[] Other Pacific Islander- Print race below _______
[] Korean
[] Some other race - Print race below _______
[] Vietnamese
[] Other Asian - Print race _______