Self Identification Form

Exit Survey »

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:

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