Form Sb.eesht.10.ga - Employee Enrollment Form Page 4
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4I. Census Information (optional)
NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with
enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.
1. Race, check all that apply:
White
Black, African-American
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
Other Race, please specify_______________________
2. Are you of Hispanic or Latino origin?
Yes
No
Page 4 of 4
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Parent category: Medical