Office of Minority Health

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

go to top

III. Sex

Sex Data Standard
What is your sex? ____Male ____Female

go to top

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)

go to top

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