10 Combined race on a paper questionnaire

Combined Race/Ethnicity Question

What is your race and/or ethnicity?

Select all that apply and enter additional details in the spaces below.

 White – Provide details below.

 English  German  Irish

 Italian  Polish  Scottish

Enter, for example, French, Swedish, Norwegian, etc.

 Hispanic or Latino – Provide details below.

 Mexican  Puerto Rican  Salvadoran

 Cuban  Dominican  Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

 Black or African American – Provide details below.

 African American  Jamaican  Haitian

 Nigerian  Ethiopian  Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

 Asian – Provide details below.

 Chinese  Asian Indian  Filipino

 Vietnamese  Korean  Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

 American Indian or Alaska Native – Enter, for example, Navajo Nation,

Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of

Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

 Middle Eastern or North African – Provide details below.

 Lebanese  Iranian  Egyptian

 Syrian  Iraqi  Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

 Native Hawaiian or Pacific Islander – Provide details below.

 Native Hawaiian  Samoan  Chamorro

 Tongan  Fijian  Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

 Some other race and/or ethnicity – Provide details below.