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.
0-11^th grade. Enter highest year completed: _____ 12^th 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 Bachelor’s degree (e.g., BA, AB, BS). Enter BACHELOR’S Master’s degree (e.g., MA, MS, MEd, MSW, MBA). Enter MASTER’S Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS, DVM, LLB, JD, RN, NP, PA). Enter DOCTORATE or PROFESSIONAL: __________________		0-11^th grade. Enter highest year completed: _____ 12^th 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 Bachelor’s degree (e.g., BA, AB, BS). Enter BACHELOR’S Master’s degree (e.g., MA, MS, MEd, MSW, MBA). Enter MASTER’S Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS, DVM, LLB, JD, RN, NP, PA). Enter DOCTORATE or PROFESSIONAL: __________________