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2012
March
S
Self Identification Form
Self Identification Form
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Name (This will only be used for the purposes of keeping track of who completed)
Position
Board
Staff
My gender is:
Female
Male
Transgender
My race* is (please choose one race with which you most closely identify):
African-American/Black
Asian (including South Asian)
Native American or Alaskan Native
Native Hawaiian/Pacific Islander
White
Multiracial
If you chose Multiracial in the previous questions, please indicate all race with which you identify:
White
African American/Black
Asian
Native Hawaiian
Native American
My ethnicity* is (please indicate if you identify with the following ethnicities):
Hispanic/Latino (any race)
Please indicate if you identify as any of the following:
Lesbian, Gay, Bisexual, Transgender
Person with a significant long-term disability (hearing, vision, cognitive, ambulatory, self-care, independent living, and some other sensory, physical, immune, mental or other impairment that substantially limits a major life activity)
Comments:
*The ACLU nation Board has asked us to keep statistics for these racial and ethnic groups, as well as any notes that board members add. Thank you for your participation
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