Data Collection Form - Illinois State Board Of Education

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Illinois State Board of Education
U.S. Department of Education Race and Ethnicity Data Standards
DATA COLLECTION FORM
Student’s Name:
School:
INSTRUCTIONS: This form is to be completed by the parent or guardian and both questions must be
answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If you
decline to respond to either question, the school district is required to provide missing information by
observer identification.
This race and ethnicity data will be used in the same manner as previously collected data, e.g., in
reporting and analyzing test results by race and ethnicity. The information will not be used to check
immigration status, and the confidentiality of the individual student information will be protected.
Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race). Choose only one.
No, not Hispanic/Latino
Yes, Hispanic/Latino
The question above is about ethnicity, not race.
No matter which answer you selected,
continue and respond to the question below by marking one or more boxes to indicate what
you consider this student’s race to be.
Part B. What is the student’s race? Choose one or more.
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
tribal affiliation or community attachment.)
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.)
Black or African American (A person having origins in any of the black racial groups
of Africa.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.)
_________________________________________________________________________________
Note: Data collected on this form will be maintained by the school district for three years. However,
when there is litigation, a claim, an audit, or another action involving this record, the original response
must be retained until the completion of the action.
Illinois State Board of Education, Division of Data Analysis and Progress Reporting
December 2009

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