What is your race? (One or more How did that person help you? categories may be selected.) Check all that apply. 1 White 1 Read the questions to me 2 Black or African American 2 Wrote down the answers I 3 American Indian or Alaska gave Native 3 Answered the questions for 4 Asian Indian me 5 Chinese 4 Translated the questions into 6 Filipino my language 7 Japanese 5 Helped in some other way 8 Korean (please print): 9 Vietnamese ________________________ 10 Other Asian 11 Native Hawaiian Thank you. Please return the 12 Guamanian or Chamorro survey in the enclosed envelope 13 Samoan 14 Other Pacific Islander to: VENDOR’S NAME Did someone help you complete STREET ADDRESS 1 this survey? STREET ADDRESS 2 1 Yes CITY, STATE, ZIP 2 No Thank you. Please return the completed survey in the postage-paid envelope. Who helped you complete this survey? 1 A family member 2 A friend 3 A staff member at the dialysis center 4 Someone else (please print): ________________________
What is your race? (One or more categories may be selected.) 1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander Did someone help you complete this survey? 1 Yes 2 No Thank you. Please return the completed survey in the postage-paid envelope. Who helped you complete this survey? 1 A family member 2 A friend 3 A staff member at the dialysis center 4 Someone else (please print): ________________________ How did that person help you? Check all that apply. 1 Read the questions to me 2 Wrote down the answers I gave 3 Answered the questions for me 4 Translated the questions into my language 5 Helped in some other way (please print): ________________________ Thank you. Please return the survey in the enclosed envelope to: VENDOR’S NAME STREET ADDRESS 1 STREET ADDRESS 2 CITY, STATE, ZIP
ICH_SurveyAdminManual_Ver4_Feb2016.docx