Questionnaire Text

Questionnaire form view entire document: text image

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. -- ______________________________________

Questionnaire instructions view entire document: text image

Please answer BOTH Question 5 about Hispanic origin and Question 6 about race. For this survey, Hispanic origins are not races.

5. A person is of Hispanic, Latino, or Spanish 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, another Hispanic, Latino, or Spanish origin" box, print the name of the specific origin.

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

This question should be answered by ALL persons.