Patient Demographics Questionnaire Template printable pdf download

PATIENT DEMOGRAPHICS QUESTIONNAIRE—Self-Administered

Target Audience:

Patients and their Families

Purpose:

This questionnaire is to be self-administered by patients or their families,

and asks for information on patient race, ethnicity, and language abilities

and preferences.

Instructions for Use:

The sample questionnaire was designed to follow the most current

recommendations regarding accurate self-reported patient race and

ethnicity as set forth by the Institute of Medicine (IOM), while maintaining

categories and rules for rolling up categories that are consistent with

current state reporting requirements (questions 1, 2, and 4). For ethnicity,

race, and language, facilities may use more granular categories for their

specific patient populations.

Guidelines for Rolling Up Categories to Match Current Reporting

Requirements

Facilities may choose to collect more detailed race and ethnicity

information from patients than OSHPD’s current reporting categories,

according to their patient population and needs. In these instances,

responses need to be rolled-up into one of the existing reporting

categories. The sample questionnaire questions are more granular than

current OSHPD reporting requirements.

1. If a patient reports multiple races in question #2, and does not identify

as one race in particular for question # 3, then the hospital or clinic

should report the patient as “Other” to OSHPD.

2. For question #1, if “Yes”, granular ethnicity categories may be selected

from a national standard set based on ancestry (e.g., Centers for

Disease Control and Prevention [CDC]/HL7 Race and Ethnicity Code

Set 1.0). Facilities should select categories from the set that are

applicable to their patient population.

3. For question #5, the National Uniform Billing Committee (NUBC) cites

Code Source International Organization for Standardization (ISO) 639-

2 for the language codes for public health data reporting.

Patient Demographics Questionnaire Template