Spectrum Ethnic and Racial Demographic Designation Form

From the MN Department of Education

Student's Full Name: Student's Full Name: First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Student's Grade

Student's Grade Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
Schools are required to report ethnicity and race to the state and to the U.S. Department of Education. Because of recent changes to Minnesota state law, Minnesota disaggregates each category into detailed groups to further represent our student populations. Parents or guardians are not required to answer the federal questions (in bold) for their children. If you choose not to answer the federal questions (in bold), federal law requires schools to choose for you. This is a last resort—we prefer if parents or guardians complete the form.

State questions are labeled as “Optional” and schools will not fill in this information for you. This information helps improve teaching and learning for everyone and helps us accurately identify and advocate for students currently underserved. The information this form collects is considered private information. You can review the privacy notice to learn more about the purpose of collecting this information, how it will be used and not used, and how the detailed groups were identified. The privacy notice can be found in our Frequently Asked Questions: Ethnic and Racial Designation Form.

The privacy notice can be found on the MN Department of Education website under
Frequently Asked Questions: Ethnic and Racial Designation Form.
https://education.mn.gov/MDE/fam/count/
Is the student Hispanic/Latino as defined by the federal government? The federal definition includes persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.1

[You must select “yes” or “no” to this question.]

Is the student Hispanic/Latino as defined by the federal government? The federal definition includes persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.1

[You must select “yes” or “no” to this question.] Yes (If yes, go to Question A) No (if no, skip next question and go to Question 1)

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Optional Question A:
If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

Optional Question A:
If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff): Decline to indicate Colombian Ecuadorian Guatemalan Mexican Puerto Rican Salvadoran Spaniard/Spanish/Spanish-American Other Hispanic/Latino Unknown
[Select “yes” to at least one of the Questions (1-6) below.]
Question 1: Does the student identify as American Indian or Alaska Native as defined by the state of Minnesota? The state of Minnesota definition includes persons having origins in any of the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition. [This question is needed to calculate state aid/funding.]

Question 1: Does the student identify as American Indian or Alaska Native as defined by the state of Minnesota? The state of Minnesota definition includes persons having origins in any of the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition. [This question is needed to calculate state aid/funding.] Yes (If yes, go to Question 1a) No (if no, skip next question and go to Question 2)
Optional Question 1a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

Optional Question 1a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff): Decline to indicate Anishinaabe/Ojibwe Cherokee Dakota/Lakota Other North American Indian Tribal Affiliation Unknown
Question 2: Is the student American Indian from South or Central America?

Question 2: Is the student American Indian from South or Central America? Yes (Go to Question 3) No (Go to Question3)
Question 3: Is the student Asian as defined by the federal government? The federal definition includes persons 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.1

Question 3: Is the student Asian as defined by the federal government? The federal definition includes persons 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.1 Yes (If yes, go to Question 3a) No (if no, skip next question and go to Question 4)

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Optional Question 3a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

Optional Question 3a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff): Decline to indicate Asian Indian Burmese Chinese Filipino Hmong Karen Korean Vietnamese Other Asian Unknown
Question 4: Is the student black or African American as defined by the federal government? The federal definition includes persons having origins in any of the black racial groups of Africa.1

Question 4: Is the student black or African American as defined by the federal government? The federal definition includes persons having origins in any of the black racial groups of Africa.1 Yes (If yes, go to Question 4a) No (if no, skip next question and go to Question 5)

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Optional Question 4a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

Optional Question 4a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff): Decline to indicate African-American Ethiopian-Oromo Ethiopian-Other Liberian Nigerian Somali Other Black Unknown
Question 5: Is the student Native Hawaiian or Other Pacific Islander as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.1

Question 5: Is the student Native Hawaiian or Other Pacific Islander as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.1 Yes (Go to Question 6) No (Go to Question 6)

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Question 6: Is the student white as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.1

Question 6: Is the student white as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.1 Yes No

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Name of person completing this form: Name of person completing this form: First Last
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Spectrum Ethnic and Racial Demographic Designation Form

Spectrum Ethnic and Racial Demographic Designation Form

[Select “yes” to at least one of the Questions (1-6) below.]