Patient Demographics Questionnaire Template (Page 2 of 4) in pdf

PATIENT DEMOGRAPHICS QUESTIONNAIRE—Self-Administered

Racial and Ethnic Categories

Respondents are asked to indicate whether they are Hispanic,

THNICITY

Latino, or Spanish Origin or not. Patients who answer “Yes” are asked to

specify their place(s) of origin.

Five racial categories are available on the form. Patients who

ACE

choose one or more racial category will be asked which race they most

identify with.

White—Person having origins in any of the original peoples of Europe, the

Middle East, or North Africa.

Black or African American—Person having origins in any of the black

racial groups of Africa; includes terms such as “Haitian” or “Negro.”

American Indian or Alaska Native—Person having origins in any of the

original peoples of North and South America (including Central America),

and who maintains tribal affiliation or community attachment.

Asian*—Person having origins in any of the original peoples of the Far

East, Southeast Asia, or the Indian subcontinent, including, Cambodia,

China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand,

and Vietnam.

Native Hawaiian or Other Pacific Islander*—Person having origins in

any of the original peoples of Hawaii, Guam, Samoa, or other Pacific

Islands.

* The reporting requirements for the OSHPD Emergency Department (ED)

and Ambulatory Surgery (AS) databases differ from Inpatient (IP)

admissions. For ED and AS visits, Asians and Pacific Islanders are

reported as separate categories, while for IP admissions, they are

reported as a combined category. If an admitted patient self-identifies as

“Native Hawaiian or Other Pacific Islander”, the hospital or clinic would

report that patient’s race as the combined “Asian/Pacific Islander” to

OSHPD. In the ED and AS databases, this patient’s race should be

reported as “Pacific Islander”.

This refers to the language that a person usually or

RINCIPAL

ANGUAGE

regularly uses, and most closely corresponds with Question #4 below. It

is the language that a person is most conversant in and, if non-English

speaking, the language for which he/she would need an interpreter.

Patient Demographics Questionnaire Template Page 2