Race and Ethnicity Identification Form
Student’s Name____________________________________
Under Federal and State law the racial and ethnic classification used to describe students in public schools in
North Carolina have been modified.
ETHNICITY: Are you of Hispanic or Latino Origin? ☐ Yes ☐ No
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.)
RACE: Read the descriptions below and check the circle or circles that indicate this student’s race. You must
select at least one race, regardless of ethnicity designation. More than one response can be selected.
Select one or more that apply:
☐
American Indian or Alaskan Native
(Not Hispanic or Latino)
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 (Not Hispanic or Latino)
A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent
including, for example, Bangladesh, Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Sri
Lanka, Thailand, and Vietnam.
☐Black or African American
(Not Hispanic or Latino)
A person having origins in any of the black racial groups of
Africa.
☐
Native Hawaiian or Other Pacific
Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
☐White or Caucasian
(Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe,
the Middle East, or North Africa.
I verify that the information on this form is accurate.
____________________________________ _____________________________________
Parent/Guardian Signature Date
I refuse to re-identify the race and ethnicity of this student.
____________________________________ _____________________________________
Parent/Guardian Signature Date
_______________________________________________________________________________
FOR SCHOOL USE ONLY
I am the observer who completed this form due to parent/guardian refusal to re-identify.
____________________________________ _____________________________________
Observer Signature Date
