Peninsula College - Information request for Federal and State Reporting
Completing this form will enable Peninsula College to report ethnic and racial information requested by the U.S.
Department of Education. It will also allow Peninsula College to assess the many talents and skills that are available
throughout the workforce, evaluate recruiting efforts, and ensure equal employment opportunity. We ask your
voluntary cooperation in responding to the questions below. This information will be treated as confidential, and will
be available only to authorized personnel. Revised 7/2009
Name (Last, First, Middle Initial) Position Date of Birth Social Security Number
1. Part A. Are you Hispanic or Latino?
No, not Hispanic or Latino. 2. Gender Male Female
Yes, Hispanic or Latino. If “yes,” choose one:
Mexican, Mexican American, Chicano (722) 3. Have you ever been on active duty in the U.S. Armed
Puerto Rican (727) Forces?
Cuban (709) Yes No Dates:
Other Hispanic or Latino. Please specify: Vietnam-era Veteran
The above part of the question is about ethnicity, not race.
If you marked “No, not Hispanic or Latino”, please 4. Disability* (please check all that apply)
continue to answer the following by marking one or more Not Disabled Ambulatory/ Mobility (1)
boxes to indicate what you consider your race to be. Visual (2) Hearing (3)
1. Part B. What is your race? (Choose one or more) Multiple Disabilities
Black or African American (870) Other (9)
Caucasian/White (800) * Any person who has a physical or mental impairment
which substantially limits one or more major life
American Indian or Alaska Native activity; has a record of such an impairment or is
American Indian (597) regarded as having such an impairment.
Please specify tribe:
Aleut (941) Please let us know how you discovered this vacancy by
Other Native American: checking the appropriate box(es).
Peninsula College Website
Asian WA State Board for Community &
Chinese (605) Japanese (611) Technical Colleges (sbctc.ctc.edu)
Cambodian (604) Laotian (613) Other website: Please specify
Filipino (608) Vietnamese (619) Port Angeles Daily News
Korean (612) Other Asian – Please Professional organization
specify Peninsula College employee or other
Native Hawaiian or Other Pacific Islander Other: Please specify
Native Hawaiian (653)
Pacific Islander. Please specify
Caucasian/White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American: A person having origins in any of the black racial groups of Africa.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including
Central America), and who maintains cultural identification through tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other