Questionnaire Text

Questionnaire form view entire document:  text  image

6. What is Person X's race? Mark (X) one or more boxes.
[ ] White
[ ] Black or African Am.
[ ] American Indian or Alaska Native -- Print name of enrolled or principal tribe. --> __________________
[ ] Asian Indian
[ ] Japanese
[ ] Chinese
[ ] Korean
[ ] Filipino
[ ] Vietnamese
[ ] Other Asian -- Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on._________________________
[ ] Native Hawaiian
[ ] Guamanian or Chamorro
[ ] Samoan
[ ] Other Pacific Islander -- Print race, for example, Fijian, Tongan, and so on.
[ ] Some other race -- Print race. --> ____________________________________________________
Questionnaire instructions view entire document:  text  image

6. Mark all boxes for the appropriate races.
The concept of race, as used by the Census Bureau, reflects self-identification by individuals according to the race or races with which they identify.
The instruction before question 5, "For this survey, Hispanic origins are not races" reflects the federal government's treatment of Hispanic origin and race as separate and distinct concepts. People who identify their origin as Hispanic, Latino, or Spanish may be of any race.
People may choose to provide two or more races either by marking two or more race response boxes, by providing multiple write-in responses, or by some combination of marking boxes and writing in responses.
If you mark the "American Indian or Alaska Native" box, also print the name of the tribe(s) in which the person is enrolled. If the person is not enrolled in a tribe, print the name of the person's enrolled or principle tribe(s) in the space provided (for example, Navajo nation, Blackfeet Tribe, Muscogee (Creek) nation, Mayan, Doyon, native Village of Barrow Inupiat Traditional Government, and so on).
If you mark the "Other Asian" box, print the name of the specific Asian group(s) in the space provided (for example, Pakistani, Cambodian, Hmong, Laotian, Bangladeshi, and so on.)
If you mark the "Other Pacific Islander" box, print the name of the specific Pacific Islander group(s) in the space provided (for example, Tongan, Fijian, Marshallese, Palauan, Tahitian, Papua New Guinean, and so on.)
If you mark the "Some other race" box, print the race(s) or group(s) in the space provided.
This question should be answered by ALL persons.