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Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status

I and II. Race and Ethnicity

Ethnicity Data Standard Categories
Are you Hispanic, Latino/a, or Spanish origin
(One or more categories may be selected)
  1. ____No, not of Hispanic, Latino/a, or Spanish origin
  2. ____Yes, Mexican, Mexican American, Chicano/a
  3. ____Yes, Puerto Rican
  4. ____Yes, Cuban
  5. ____Yes, another Hispanic, Latino, or Spanish origin
ArrowThese categories roll-up to the Hispanic or Latino category of the OMB standard


Race Data Standard Categories
What is your race?
(One or more categories may be selected)
  1. ____White
  2. ____Black or African American
  3. ____American Indian or Alaska Native

Arrow
These categories are part of the current OMB standard


  1. ____Asian Indian
  2. ____Chinese
  3. ____Filipino
  4. ____Japanese
  5. ____Korean
  6. ____Vietnamese
  7. ____Other Asian

Arrow


These categories roll-up to the Asian category of the OMB standard


  1. ____Native Hawaiian
  2. ____Guamanian or Chamorro
  3. ____Samoan
  4. ____Other Pacific Islander

ArrowThese categories roll-up to the Native Hawaiian or Other Pacific Islander category of the OMB standard


III. Sex

Sex Data Standard
What is your sex?
  1. ____Male
  2. ____Female


IV. Primary Language

Data Standard for Primary Language
How well do you speak English? (5 years old or older)
  1. ____Very well
  2. ____Well
  3. ____Not well
  4. ____Not at all

Data Collection for Language Spoken (Optional)

  1. Do you speak a language other than English at home? (5 years old or older)
    1. ____Yes
    2. ____No

    For persons speaking a language other than English (answering yes to the question above):
  2. What is this language? (5 years old or older)
    1. ____Spanish
    2. ____Other Language (Identify)


V. Disability Status

Data Standard for Disability Status

  1. Are you deaf or do you have serious difficulty hearing?
    1. ____Yes
    2. ____No

  2. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
    1. ____Yes
    2. ____No

  3. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older)
    1. ____Yes
    2. ____No

  4. Do you have serious difficulty walking or climbing stairs? (5 years old or older)
    1. ____Yes
    2. ____No

  5. Do you have difficulty dressing or bathing? (5 years old or older)
    1. ____Yes
    2. ____No

  6. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older)
    1. ____Yes
    2. ____No

Last Modified: 9/6/2013 8:11:00 AM