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MEDICAL HISTORY FORMPatient Name:___ Birth Date:___ Todays Date:___Race: American Indian Asian Black Hispanic White Other___Ethnicity: Hispanic NonHispanic or LatinoLanguage:___. Reason for todays

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Start by clearly identifying the sections for race and national origin on the form.

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Provide accurate and truthful information about your race and national origin.

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Who needs race and national origin?

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Employers may request information about race and national origin for reporting purposes or to ensure compliance with equal opportunity regulations.

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Government agencies may collect data on race and national origin for statistical analysis and program planning.

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What is race and national origin?

Race and national origin refer to the categorization of individuals based on their heritage, ancestry, and cultural identity. Race typically involves physical characteristics such as skin color, while national origin relates to the country or culture from which a person originates.

Who is required to file race and national origin?

Individuals or entities that are subject to federal reporting requirements, such as employers, educational institutions, and certain organizations, are required to file race and national origin information.

How to fill out race and national origin?

To fill out race and national origin information, individuals should select the appropriate categories that best represent their racial and ethnic identity, usually from provided options on forms or surveys.

What is the purpose of race and national origin?

The purpose of collecting race and national origin data is to monitor compliance with civil rights laws, identify discrimination, and promote equal opportunities in various sectors such as employment and education.

What information must be reported on race and national origin?

The information reported typically includes the participant's self-identified race and national origin, often categorized into specific groups as defined by federal standards.

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