EXAMPLE PATIENT DEMOGRAPHICS QUESTIONNAIRE

Administered (In-Person or Over the Phone) by Hospital or Clinic Personnel

Target Audience: Hospital Admissions/Clinic Registration Personnel

Purpose: This sample questionnaire, to be administered by hospital or clinic personnel, asks patients to provide information on their race, ethnicity, and language abilities and preferences. A script is provided for staff to use to help introduce the questions that follow.

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.

Racial and Ethnic Categories

ETHNICITY: Respondents are asked to indicate whether they are Hispanic, Latino, or Spanish Origin or not. Patients who answer "Yes" are asked to specify their place(s) of origin.

RACE: Five racial categories are available on the form. Patients who 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".

PRINCIPAL LANGUAGE This refers to the language that a person usually or 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.

We want to make sure that all of our patients get the best care possible. We would like you to tell us your racial and ethnic background so that we can review the best treatment that our patients can receive and make sure that everyone of every background gets the highest quality of care. It is also important that we know your preferred spoken language so that you and your healthcare team can have good communication.

We will keep this information private and will update it in your medical record. Your answers are confidential. You need not answer any question you prefer not to answer.

1. Are you of Hispanic, Latino, or Spanish origin? (Mark ONE box.)
   Yes______________________ (specify (e.g. Mexican, Puerto Rican, Cuban, etc.))
   No, not Hispanic, Latino, or Spanish origin



2. What is your race? (Mark one or more boxes.)
   White/Caucasian
   Black/African American
   American Indian/Alaska Native
   Asian
   Native Hawaiian or Other Pacific Islander
   Some other race:__________________(specify)
   Prefer not to answer



3. IF MORE THAN ONE RACE (Question #2) IS CHECKED: Do you identify with any one race in particular?
   Yes ________________(specify)
   No



4. What language do you feel most comfortable using when speaking to a doctor or nurse?
   English
   Spanish
   Another language:______________(specify)



5. What language do you prefer receiving written medical information?
   English
   Spanish
   Another language:______________(specify)



6. How well do you speak English?
   Very well
   Well
   Not well
   Not at all
   Patient does not understand question
   Patient is unconscious/unavailable to answer
   Prefer not to answer



7. How well do you understand English?
   Very well
   Well
   Not well
   Not at all
   Patient does not understand question
   Patient is unconscious/unavailable to answer
   Prefer not to answer



8. Would it help you to have an interpreter when you speak with a doctor or nurse?
   Yes
   No
   Don't know