RACE/ETHNICITY AND EDUCATION WORKSHEET (For Reference Only)

RACE/ETHNICITY (FATHER/PARENT)

RACE/ETHNICITY (MOTHER/PARENT)

HISPANIC, LATINO, SPANISH (check 1 box).Enter specific origin on the certificate.

HISPANIC, LATINA, SPANISH (check 1 box).Enter specific origin on†††† the certificate.

Is the FATHER/PARENT Hispanic/Latino/Spanish?

No, not Hispanic/Latino/Spanish

Yes, Mexican, Mexican American, Chicano

Yes, Central American

Yes, South American

Yes, Cuban

Yes, Puerto Rican

Yes, Other Hispanic/Latino/Spanish (Specify):

†††††† ____________________________________

Is the MOTHER/PARENT Hispanic/Latina/Spanish?

No, not Hispanic/Latina/Spanish

Yes, Mexican, Mexican American, Chicana

Yes, Central American

Yes, South American

Yes, Cuban

Yes, Puerto Rican

Yes, Other Hispanic/Latina/Spanish (Specify):

†††††† ____________________________________

RACE(check 1, 2 or 3 boxes).Enter up to 3 races on the certificate.

RACE (check 1, 2 or 3 boxes).Enter up to 3 races on the certificate.

The FATHER/PARENT is:

White

Black or African American

American Indian or Alaska Native

††††† (includes North, South, or Central

††††† American Indian, Aleut or
††††† Alaska Native)

††††† Specify Tribe(s):______________

†††† ††___________________________

Native Hawaiian

Guamanian

Samoan

Other Pacific Islander (Specify):

†††††† _________________________

 

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Japanese

Korean

Laotian

Thai

Vietnamese

Other Asian (Specify):

†††††________________________

The MOTHER/PARENT is:

White

Black or African American

American Indian or Alaska Native
††††† (includes North, South, or Central
††††† American Indian, Aleut or
††††† Alaska Native)

††††† Specify Tribe(s):______________

†††††† ___________________________

Native Hawaiian

Guamanian

Samoan

Other Pacific Islander (Specify):

††††† __________________________

 

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Japanese

Korean

Laotian

Thai

Vietnamese

Other Asian (Specify):

††††† ________________________

Other (Specify):______________________________________________

Other (Specify):______________________________________________

Other (Specify):______________________________________________

Other (Specify):______________________________________________

Other (Specify):______________________________________________

Other (Specify):______________________________________________

EDUCATION (FATHER/PARENT)

EDUCATION (MOTHER/PARENT)

Check 1 box that best describes the highest degree or level of school completed by the FATHER/PARENT at the time of the delivery.Enter education degree or level on the certificate.

Check 1 box that best describes the highest degree or level of school completed by the MOTHER/PARENT at the time of the delivery.Enter education degree or level on the certificate.

0-11th grade.Enter highest year completed: _____

12th grade; no diploma.Enter 12 ND

High school graduate or GED completed.Enter HS GRADUATE or GED

Some college credit, but no degree.Enter SOME COLLEGE

Associate degree (e.g., AA, AS).Enter ASSOCIATE

Bachelorís degree (e.g., BA, AB, BS).Enter BACHELORíS

Masterís degree (e.g., MA, MS, MEd, MSW, MBA).Enter MASTERíS

Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS,

†††††† DVM, LLB, JD, RN, NP, PA).

†††††† Enter DOCTORATE or PROFESSIONAL: __________________

0-11th grade.Enter highest year completed: _____

12th grade; no diploma.Enter 12 ND

High school graduate or GED completed.Enter HS GRADUATE or GED

Some college credit, but no degree.Enter SOME COLLEGE

Associate degree (e.g., AA, AS).Enter ASSOCIATE

Bachelorís degree (e.g., BA, AB, BS).Enter BACHELORíS

Masterís degree (e.g., MA, MS, MEd, MSW, MBA).Enter MASTERíS††††

Doctorate (e.g., PhD, EdD) or Professional degree(e.g., MD, DO, DDS,

†††††† DVM, LLB, JD, RN, NP, PA).

†††††† Enter DOCTORATE or PROFESSIONAL: __________________