What is your race? You may select What is that language? one or more categories. Spanish White Other Language or African American (PLEASE SPECIFY): American Indian or Alaska (Please print.) Native Indian Did someone help you complete Chinese this survey? Filipino Yes Japanese No If No, go to END. Korean How did that person help you? Vietnamese all that apply. Other Asian Read the questions to me Native Hawaiian Wrote down the answers I Guamanian or Chamorro gave Samoan Answered the questions for me Other Pacific Islander Translated the questions into How well do you speak English? my language Helped in some other way: Very well (EXPLAIN): Well Not well (Please print.) Not at all No one helped me complete this survey Do you speak a language other than English at home? END Yes No If No, go to #36
What is your race? You may select one or more categories. White or African American American Indian or Alaska Native Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander How well do you speak English? Very well Well Not well Not at all Do you speak a language other than English at home? Yes No If No, go to #36 What is that language? Spanish Other Language (PLEASE SPECIFY): (Please print.) Did someone help you complete this survey? Yes No If No, go to END. How did that person help you? all that apply. Read the questions to me Wrote down the answers I gave Answered the questions for me Translated the questions into my language Helped in some other way: (EXPLAIN): (Please print.) No one helped me complete this survey END
OASCAHPS_ProtocolsGuidelinesManual_v1.1.docx