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.
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