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
   Central American
   Mexican
   South American
   Other Hispanic or Latino/a/x
  If "Other Hispanic or Latino/a/x", please describe:
• Native Hawaiian and Pacific Islander
   CHamoru (Chamorro)
   Marshallese
   Communities of the Micronesian Region
   Native Hawaiian
   Samoan
   Other Pacific Islander
  If "Other Pacific Islander", please describe: 
• White
   Eastern European
   Slavic
   Western European
   Other White
  If "Other White", please describe:
• 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
  If "Other African (Black)" and/or "Other Black", please describe:
• 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
  If "Other Asian", please describe: 
• Other Categories 
   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?

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? 

      YesNoDon't knowDon't want to answer

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?

No

Don't know

Don't want to answer

Don't know what this question is asking

  If yes, at what age did this condition begin?  

11. Do you have difficulty dressing or bathing?

No

Don't know

Don't want to answer

Don't know what this question is asking

 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?

No

Don't know

Don't want to answer

Don't know what this question is asking

 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: