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Data Collection
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Final Standards
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)
____No, not of Hispanic, Latino/a, or Spanish origin
____Yes, Mexican, Mexican American, Chicano/a
____Yes, Puerto Rican
____Yes, Cuban
____Yes, another Hispanic, Latino, or Spanish origin
These 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)
____White
____Black or African American
____American Indian or Alaska Native
These categories are part of the current OMB standard
____Asian Indian
____Chinese
____Filipino
____Japanese
____Korean
____Vietnamese
____Other Asian
These categories roll-up to the Asian category of the OMB standard
____Native Hawaiian
____Guamanian or Chamorro
____Samoan
____Other Pacific Islander
These categories roll-up to the Native Hawaiian or Other Pacific Islander category of the OMB standard
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III. Sex
Sex Data Standard
What is your sex?
____Male
____Female
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IV. Primary Language
Data Standard for Primary Language
How well do you speak English? (5 years old or older)
____Very well
____Well
____Not well
____Not at all
Data Collection for Language Spoken (Optional)
Do you speak a language other than English at home? (5 years old or older)
____Yes
____No
For persons speaking a language other than English (answering yes to the question above):
What is this language? (5 years old or older)
____Spanish
____Other Language (Identify)
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V. Disability Status
Data Standard for Disability Status
Are you deaf or do you have serious difficulty hearing?
____Yes
____No
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
____Yes
____No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older)
____Yes
____No
Do you have serious difficulty walking or climbing stairs? (5 years old or older)
____Yes
____No
Do you have difficulty dressing or bathing? (5 years old or older)
____Yes
____No
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)
____Yes
____No
Last Modified: 6/1/2018 5:08:00 PM