Ethnicity / Race Reporting
7/2013
Please answer questions in both categories.
1. Ethnic Origin:
No, not Hispanic or Latino
Yes, Hispanic or Latino
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race)
2. Race Origin (choose one or more):
White
(A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa)
American Indian or Alaskan Native
(A person having origins in any of the original peoples of North and South
America, including Central America, and who maintains tribal affiliation or
community attachment)
Asian
(A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam)
Black or African American
(A person having origins in any of the black racial groups of Africa)
Native Hawaiian or Other Pacific Islander
(A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands)
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Employee Name (PRINTED)
_____________________________ _________________________
Employee Signature Date
