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Questionnaire Text

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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 _______