Name

First Name

Last Name

Date *

MM

DD

YYYY

Which of the following best describes you?

American Indian and Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. This category includes people who indicate their race as "American Indian or Alaska Native" or report entries such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, or Nome Eskimo Community. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, India, China, the Philippine Islands, Japan, Korea, or Vietnam. It includes people who indicate their race as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and “Other Asian” or provide other detailed Asian responses such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc. Black: A person having origins in any of the Black racial groups of Africa. It includes people who indicate their race as "Black or African American," or report responses such as African American, Jamaican, Haitian, Nigerian, Ethiopian, or Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, Bahamian, etc. Hispanic or Latine: Includes individuals of Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, and other Central or South American or Spanish culture or origin. Native Hawaiian and Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicate their race as “Native Hawaiian,” “Chamorro,” “Samoan,” and “Other Pacific Islander” or provide other detailed Pacific Islander responses such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as "White" or report responses such as German, Irish, English, Italian, Lebanese, and Egyptian. The category also includes groups such as Polish, French, Iranian, Slavic, Cajun, Chaldean, etc. Two or more races. People may choose to provide two or more races either by checking two or more race response check boxes, by providing multiple responses, or by some combination of check boxes and other responses. The race response categories shown on the questionnaire are collapsed into the five minimum race groups identified by OMB, and the Census Bureau’s “Some Other Race” category. For data product purposes, “Two or More Races” refers to combinations of two or more of the following race categories: White, Black, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or Some Other Race.

Asian

American Indian and Alaska Native

Black

Hispanic/Latine

Native Hawaiian and Other Pacific Islander

White

Other