Name *

Note: Middle name or initial may be included in the First Name field. For example, 'Jane S.'

First Name

Last Name

Underrepresented minority groups (URM): The information gathered in the following two questions will be compiled for reporting purposes only. CIDID is required to report on the involvement of URMs. Individual names will not be reported. *

Question 1. Are you:

Hispanic or Latina/Latino (See Note below)

Not Hispanic or Latina/Latino

Prefer Not to Answer

URM (continued) *

Question 2. Are you:

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

White or Caucasian

Other

Prefer Not to Answer