SSA-108 DRAFT (Proposed RECS Questions)

Voluntary Race and Ethnicity Information

The information we request below is for informational and statistical purposes only. Answering these questions is voluntary and will not affect any decisions about your application for benefits. The information will be kept private and used for authorized Federal agency reporting purposes only.

Are you Hispanic or Latino?
Answer	Definition
□ Yes	Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or Other Spanish Culture or origin, regardless of race.
□ No
What is your race? Please select one or more.
Answer	Definition
□ Alaska Native	A person having origins in any of the original peoples of Alaska who maintains tribal affiliation or community attachment. For example, Aleuts, Athabascans, Haidas, Inupiat, Tlingits, and Yupiks.
□ American Indian	A person having origins in any of the original peoples of Central, North (except Alaska), and South America, and who maintains a 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. This includes those who describe themselves as Haitian.
□ Native Hawaiian	A person having origins in any of the original peoples of Hawaii.
□ Other Pacific Islander	A person having origins in any of the original peoples of Guam, Samoa, New Zealand, or other Pacific Islands.
□ White	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Please supply your name and Social Security number if mailing this form to your local office.

Name:_______________________________ SSN:____________________________

Privacy Act Notice: We are asking you to provide information about your race and ethnicity. We are collecting this information as a result of an Office of Management and Budget directive that Federal agencies collecting race and ethnicity information must do so using standards that are consistent throughout the Federal Government. The information we will collect will be used for statistical research purposes. Providing this information is voluntary. This information will not be used in any way to make a determination about you and your dependents entitlement to insurance coverage and/or monthly benefits. If you do provide us this information, we will treat it very carefully.

The Privacy Act allows us to disclose information collected solely for statistical purposes to another person or another agency under certain circumstances. Generally, we can disclose such records when there are safeguards that the record will be used solely as a statistical or research record and the person providing the information cannot be identified from any information in the record, or to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security). Whenever possible, we release information for statistical purposes only when the information cannot be associated with a particular person.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995.  You do not need to answer these questions unless we display a valid Office of Management and Budget control number.  We estimate that it will take about XX minutes to read the instructions, gather the facts, and answer the questions.  You may send comments on our time estimate above to:  SSA, 6401 Security Blvd, Baltimore, MD  21235-6401.  Send only comments relating to our time estimate to this address, not the completed form.

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