REALD/SOGI


               

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Race, Ethnicity, Language, and Disability (REALD)

 

These questions are optional and your answers are confidential. We would like you to tell us your race,
ethnicity, language and ability levels so that we can find and address health and service differences.

 

First name:      Last name:

 

Date of birth:      Today's date: 

 

Race and Ethnicity

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.

  • Hispanic and Latino/a/x
    If "Other Hispanic or Latino/a/x", please describe:
  • Native Hawaiian and Pacific Islander
     If "Other Pacific Islander", please describe: 
  • White
     If "Other White", please describe:
  • American Indian and Alaska Native
  • Black and African American
     If "Other African (Black)" and/or "Other Black", please describe:
  • Middle Eastern/North African  
  • Asian
     If "Other Asian", please describe: 
  • Other Categories  
     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?

If "Yes", please enter your primary racial or ethnic identity:

4a. What language or languages do you use at home?

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? 

     

5b. If you need or want an interpreter, what type of interpreter is preferred?

 If "Other", please describe:  

 

***Skip to question 7 if you do not use a language other than English or sign language***

 

6. How well do you speak English?

 

 *For the below questions 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***

 

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 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?  

 

Sexual Orientation and Gender Identity

1. Please describe your gender in any way you prefer:

 

2. What is your gender? (check all that apply)

 If your gender is not listed please enter it here:   

3. Are you transgender?

 

4. Please describe your sexual orientation or sexual identity in any way you want:

 

5. How do you describe your sexual orientation or sexual identity? (check all that apply):

 If your sexual orientation or sexual identity is not listed please enter it here:  

Leave this empty:

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Signature Certificate
Document name: REALD/SOGI
lock iconUnique Document ID: 60ae2f703761011fd8a74bb854b778f5e5920254
Timestamp Audit
December 12, 2022 10:49 am PSTREALD/SOGI Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202