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