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Ethnic Background Change Form

Please print, sign, and return the completed form to:

Academic Records
112 Shields Building
University Park, PA 16802-1271

Fax: 814-863-1929

Please print, sign, and return the completed form to:
Academic Records
112 Shields Building
University Park, PA 16802-1271
Fax: 814-863-1929

Identification

9-digit Penn State ID number
Please enter your PSU ID.

Federal law requires that institutions of higher education gather the following information regarding the ethnicity and race of their students and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report aggregate totals for each category.

Select the appropriate responses regarding your ethnicity and your race:

Ethnic Background

Is your ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)?

What is Your Race?

Please select one or more from the options below:

Please review your entries on this form. If all information is entered correctly, please print, sign, and submit form to the address at the top.

Student Signature

Student Signature: _________________________________________________

Date: ____________________________

Student Signature: _______________________________________ Date: __________________________

Last Revised: 2/12/09