Date of birth* (m m / d d / y y y y): *Gender: Female Unspecified Male Not reported Unknown *Ethnicity(“X” ONLY one with which you MOST CLOSELY identify): Hispanic or Latino Unknown Not Hispanic or Latino Not Reported *Race with which you identify): (“X” those American Indian or Alaska Native White Asian Unknown Black or African American Not Reported Native Hawaiian or Other Pacific Islander Additional Pediatric-specific Elements These elements are recommended for pediatric studies. *Date and time of birth: Date (m m / d d / y y y y): Time: AM 24-hour clock PM Maternal ethnicity with which the mother MOST CLOSELY identifies): (“X” ONLY one Hispanic or Latino Unknown Not Hispanic or Latino Not Reported Maternal race: those with which the mother identifies) (“X” Black or African-American American Indian or Alaska Native White Unknown Asian Not Reported Native Hawaiian or Other Pacific Islander Paternal ethnicity ONLY one with which the father MOST CLOSELY identifies): (“X”
Date of birth* (m m / d d / y y y y): *Gender: Female Male Unknown Unspecified Not reported *Ethnicity(“X” ONLY one with which you MOST CLOSELY identify): Hispanic or Latino Not Hispanic or Latino Unknown Not Reported *Race (“X” those with which you identify): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Unknown Not Reported Additional Pediatric-specific Elements These elements are recommended for pediatric studies. *Date and time of birth: Date (m m / d d / y y y y): Time: AM PM 24-hour clock Maternal ethnicity (“X” ONLY one with which the mother MOST CLOSELY identifies): Hispanic or Latino Not Hispanic or Latino Unknown Not Reported Maternal race: (“X” those with which the mother identifies) Black or African-American White Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Unknown Not Reported Paternal ethnicity (“X” ONLY one with which the father MOST CLOSELY identifies):
F0016_Demographics.docx