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Vaccine Administration Consent Form First NameMICell Phones Name Date of Birth MM/DD/Home Addressable Ethnicity White Hispanic or Latino Black/African Not Hispanic or Latino American Asian American
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Black/African American (not Hispanic or Latino).
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Individuals who identify as Black/African American and not Hispanic or Latino are required to select this option when filling out demographic information.
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Individuals must report that they identify as Black/African American and not Hispanic or Latino when selecting this option.
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