Draft Interim I-200 Student Policies Appendices

Attachment A: Sample Standardized Information Request

The introductory language must accompany any request for information regarding race, national origin, ethnicity or sex.

The following information is requested for statistical purposes only, so that the University may monitor the effectiveness of its recruitment and outreach programs. It will not be used in admission decisions. Completion of the information is voluntary; a decision not to provide this information will not result in any adverse treatment of your application.

1. What is your gender: __male __female

2. Are you of Hispanic or Latino origin? (Check all that apply.)

__No

__Yes, Mexican/Mexican American/Chicano

__Yes, Puerto Rican

__Yes, Other Hispanic or Latino (specify, e.g., Argentinean, Colombian,

Cuban, Nicaraguan, Salvadoran, Spaniard, etc.):_________________

3. What race(s) do you consider yourself? (Check all that apply.)

__Alaska Native (specify tribal/corporate affiliation):_________________

__American Indian (specify tribal/corporate affiliation):_______________

__Black or African American

__Asian American:

__Asian Indian __Chinese

__Filipino __Japanese

__Korean __Vietnamese

__Other Asian American (specify):_________________

__Pacific Islander:

__Guamanian __Hawaiian

__Samoan __Other Pacific Islander (specify)_________________

__White of Caucasian (European, Middle Eastern or North African)

__Other (specify): __________________________