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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 |
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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
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 These categories roll-up to the Hispanic or Latino category of the OMB standard
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| 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
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These categories are part of the current OMB standard |
- ____Asian Indian
- ____Chinese
- ____Filipino
- ____Japanese
- ____Korean
- ____Vietnamese
- ____Other Asian
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These categories roll-up to the Asian category of the OMB standard |
- ____Native Hawaiian
- ____Guamanian or Chamorro
- ____Samoan
- ____Other Pacific Islander
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These categories roll-up to the Native Hawaiian or Other Pacific Islander category of the OMB standard |
III. Sex
| Sex Data Standard |
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What is your sex?
- ____Male
- ____Female
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IV. Primary Language
| Data Standard for Primary Language |
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How well do you speak English? (5 years old or older)
- ____Very well
- ____Well
- ____Not well
- ____Not at all
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| Data Collection for Language Spoken (Optional) |
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- 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 |
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- 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
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Content Last Modified: 10/31/2011 10:05:00 AM
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