fit race and ethnicity tracking form (filed in client … · fit race and ethnicity tracking form...

FIT Race and Ethnicity Tracking Form (filed in Client Main Record) Agency Name: Date Completed:

Child’s Name: Date of Birth: Family Service Coordinator: (print full name)

What is this child's ethnicity? (Required: Mark ONLY one) Hispanic, Latino OR

Spanish origin

Includes: ▪ New Mexican ▪ Mexican American ▪ Chicano ▪ Puerto Rican ▪ Cuban ▪ Specify (optional):_______________

Not Hispanic, Latino or Spanish origin

What is this child's race? (Required: Mark all that apply) American Indian or

Alaskan Native OR Person having origin in the Americas

Tribe Information Required –Check ALL that apply: Alaskan Native Jicarilla Apache Nation Mescalero Apache Nation Navajo Nation Pueblo of Acoma Pueblo of Cochiti Pueblo of Isleta Pueblo of Jemez Kewa Pueblo Pueblo of Laguna Pueblo of Nambe Okay Owingeh Pueblo Pueblo of Picuris Pueblo of Pojoaque Pueblo of San Ildefonso Pueblo of San Felipe Pueblo of Sandia Pueblo of Santa Ana Pueblo of Santa Clara Pueblo of Taos Pueblo of Tesuque Ysleta Del Sur Pueblo Pueblo of Zia Pueblo of Zuni Native American – Other Tribe Native American – Tribe Unspecified

Asian OR Person having origin in the Far East, Southeast Asia or Indian subcontinent

Includes: ▪ Asian Indian ▪ Chinese ▪ Filipino ▪ Japanese ▪ Korean ▪ Vietnamese ▪ Cambodian ▪ Laotian ▪ Malaysian ▪ Thai ▪ Taiwanese ▪ Pakistani ▪ Tibetan ▪ Specify (optional):________________

Black or African American OR Person having origin in any of the Black racial groups of Africa

▪ Specify (optional): _______________

Native Hawaiian or Other Pacific Islander OR Person having origin in Hawaii or other Pacific Island

▪ Specify (optional): _______________

White OR Person having origin in Europe, Middle East or North Africa

Includes: ▪ Arab ▪ European ▪ Iranian ▪ Iraqi ▪ Middle Eastern ▪ Syrian ▪Turkish ▪ West Indian ▪ Specify (optional):_________________

How was this information obtained? (Mark only one)

Parent or Family Identification (preferred) Team Identification Combination: Team and Family Form Effective October 1, 2015