Penn State Office of the University Registrar

Ethnic Background Change Form

Please fill out this online form, print (using "Print Form" button at bottom of page), sign and:
Return to:
Academic Records
112 Shields Building
University Park, PA 16802-1271
Fax 814-863-1929

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:

Is your ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)?
What is your race (select one or more):

Please review your entries on this form. If all of the information is entered correctly, please print (using "Print Form" button at bottom), sign and submit the form to the address at the top.

Student Signature: _____________________________________ Date: ___________________

Revised 2/12/09