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Today's Date: / / PATIENT REGISTRATIONPatients Full Name Sex M F Date of Birth Patients Address Race (Circle) Asian Black Middle eastern Native Other Pacific Islander WhiteCircle One Hispanic/Not
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To fill out race and Hispanic origin information, follow these steps:
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Start by finding the designated section on the form or document where you are required to provide this information.
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Read the instructions carefully to understand how the race and Hispanic origin options are categorized.
04
Select the appropriate checkboxes or options that best represent your race and Hispanic origin.
05
If none of the provided options accurately describe your race or Hispanic origin, check the box for 'Other' and provide additional details if prompted.
06
Double-check your selections to ensure they accurately reflect your race and Hispanic origin.
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If you are unsure about how to correctly fill out this section, seek assistance from a supervisor or the appropriate authority for clarification.
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Finally, submit the form or document as instructed, making sure that your race and Hispanic origin information is included.

Who needs race and hispanic origin?

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Collecting race and Hispanic origin information is often required in demographic surveys, government forms, applications, and research studies.
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Here are some examples of who may need race and Hispanic origin information:
03
- Government agencies that use this data for statistical purposes, policy-making, or monitoring discrimination.
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- Educational institutions that utilize the information to understand diversity and assess their admission or enrollment strategies.
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- Employers who are required to report diversity statistics or follow affirmative action programs.
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- Healthcare providers who collect this information for medical research, public health tracking, or identifying health disparities.
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- Social science researchers who study patterns, trends, and inequalities in society.
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Overall, race and Hispanic origin information is gathered to better understand and address social, economic, and health-related disparities, as well as to ensure equal opportunities and access for all individuals.
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Race and Hispanic origin are categories used to classify and describe the population in terms of social and demographic characteristics.
Individuals and households are required to provide information on their race and Hispanic origin when completing certain forms, such as the Census questionnaire.
To fill out race and Hispanic origin, individuals can select the appropriate categories that best represent their racial and ethnic identity on the forms provided.
The purpose of collecting information on race and Hispanic origin is to better understand the diversity of the population and address any disparities in various social and economic factors.
Individuals may be asked to report on their race, such as White, Black or African American, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and Hispanic origin, such as Mexican, Puerto Rican, Cuban, or Other Hispanic/Latino.
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