Questionnaire Text

Questionnaire form view entire document:  text  image
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 -->


Questionnaire instructions view entire document:  text  image
5.A person is of Spanish/Hispanic/Latino origin if the person's origin (ancestry) is Mexican, Mexican American, Chicano, Puerto Rican, Cuban, Argentinean, Colombian, Costa Rican, Dominican, Ecuadoran, Guatemalan, Honduran, Nicaraguan, Peruvian, Salvadoran, from other Spanish-speaking countries of the Caribbean or Central or South America, or from Spain.

The term Mexican Am. refers to persons of Mexican-American origin or ancestry.

If you mark the "Yes, other Spanish/Hispanic/Latino" box, print the name of the specific group.

If a person is not of Spanish/Hispanic/Latino origin, answer this question by marking the "No, not Spanish/Hispanic/Latino" box.

This question should be answered for ALL persons, regardless of citizenship status.