เชื้้อ ชาติิชาติิพัันธุ์์ ภาษา และความพิการ ิ (REALD)
เชื้้อ ชาติิชาติิพัันธุ์์ ภาษา และความพิการ ิ
เชื้้อ ชาติิชาติิพัันธุ์์ ภาษา และความพิการ ิ
คำำ ถามเหล่่านี้้ไ ม่่บัังคัับ และคำำ ตอบของคุุณจะเป็็นความลัับ เราอยากให้้คุุณบอกเราเกี่่ยว กัับเชื้้อ ชาติิชาติิพัันธุ์์ ภาษาและความพิิการของคุณ ทั้ ุ ้งนี้้ เ พื่่อใ ห้เร้ าทราบและจััดการกัับความแตกต่่างในด้้านสุุขภาพและบริิการได้้
อีเมลของคุณ
*
ชื่อจริง
*
ชื่อกลาง
นามสกุล
*
วันเกิด (MM/DD/YYYY)
*
1: How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?
2: Which of the following describes your racial or ethnic identity? Please check ALL that apply.
อเมริกัิันอิินเดีียน และ ชนพื้้นเ มืืองอะแลสกา
อเมริกันอินเดียน
ชนพื้น เมืองอะแลสกา
อินนูอิท, เมทิส หรอืชนพื้น เมืองดังเดิมอ ้ ื่น ๆ ในแคนาดา
ชนพื้น เมืองในเม็กซิโก, อเมริกากลาง หรออเมริก ื าใต้
Native Hawaiian and Pacific Islander
CHamoru (Chamorro)
Marshallese
Communities of the Micronesian Region
Native Hawaiian
Samoan
Other Pacific Islander
White
Eastern European
Slavic
Western European
Other White
American Indian and Alaska Native
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Black and African American
African American
Afro-Caribbean
Ethiopian
Somali
Other African (Black)
Other Black
Middle Eastern/North African
Middle Eastern
North African
Asian
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino/a
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
Other categories
Other (please list)
Don’t know
Don’t want to answer
Other (please list)
3: If you checked more than one category above, is there one you think of as your primary racial or ethnic identity?
Please circle your primary racial or ethnic identity above.
4a: What language or languages do you use at home?
Skip to question 7 if you indicated English only
Skip to question 7 if you indicated English only
4b: In what language do you want us to communicate in person, on the phone, or virtually with you?
4c: In what language do you want us to write to you?
5a: Do you need or want an interpreter for us to communicate with you?
Yes
No
Don’t know
Don’t want to answer
5b: If you need or want an interpreter, what type of interpreter is preferred?
Spoken language interpreter
Deaf Interpreter for DeafBlind, additional barriers, or both
American Sign Language interpreter
Contact sign language (PSE) interpreter
Other
Please list other interpreter(s):
Skip to question 7 if you do not use a language other than English or sign language
Skip to question 7 if you do not use a language other than English or sign language
6: How well do you speak English?
Very Well
Well
Not Well
Not at all
Don’t know
Don’t want to answer
Your answers will help us find health and service differences among people with and without functional difficulties. Your answers are confidential. (*Please select “don’t know” if you don’t know when you acquired this condition, or “don’t want to answer” if you don’t want to answer the question.)
7: Are you deaf or do you have serious difficulty hearing?
If yes, at what age did this condition begin?
8: Are you blind or do you have serious difficulty seeing, even when wearing glasses?
If yes, at what age did this condition begin?
Please stop now if you/the person is under age 5
Please stop now if you/the person is under age 5
9: Do you have serious difficulty walking or climbing stairs?
If yes, at what age did this condition begin?
10: Because of a physical, mental or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?
If yes, at what age did this condition begin?
11: Do you have difficulty dressing or bathing?
If yes, at what age did this condition begin?
12 : Do you have serious difficulty learning how to do things most people your age can learn?
If yes, at what age did this condition begin?
13: Using your usual (customary) language, do you have serious difficulty communicating (for example understanding or being understood by others)?
If yes, at what age did this condition begin?
Please stop now if you/the person is under age 15
Please stop now if you/the person is under age 15
14: Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
If yes, at what age did this condition begin?
15: Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations?
If yes, at what age did this condition begin?
*
Send me a copy of my responses
Submit
Privacy Policy
Report Abuse