Note: Please answer both Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.
5. Is Person X 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. - ____
6. What is Person X's race?
Mark (X) one or more boxes and print origins.
[] White - Print, for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. - ____
[] Black or African Am. - Print, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. - ____
[] American Indian or Alaska Native - Print name of enrolled or principal tribe(s), for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. - ____
[] Chinese
[] Filipino
[] Asian Indian
[] Vietnamese
[] Korean
[] Japanese
[] Other Asian - Print, for example, Pakistani, Cambodian, Hmong, etc. - ____
[] Native Hawaiian
[] Samoan
[] Chamorro
[] Other Pacific Islander - Print, for example, Tongan, Fijian, Marshallese, etc. - ____
[] Some other race - Print race or origin. - ____
Person questions 1-6
Answer questions 1-6 for the first five people living or staying at this address.
- Include everyone who is living or staying here for more than 2 months.
- Include yourself if you are living here for more than 2 months.
- Include anyone else staying here who does not have another place to stay, even if they are here for 2 months or less.
- Do not include anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.
P5. Please answer "both" question 5 about Hispanic origin and question 6 about race. For this survey, Hispanic origin is not a race.