What is your race? You may select How did that person help you? one or more categories. Check all that apply. White Read the questions to me Black or African American Wrote down the answers I gave American Indian or Alaska Native Answered the questions for me Asian Indian Translated the questions into my language Chinese Helped in some other way: Filipino (EXPLAIN): Japanese Korean (Please print.) Vietnamese No one helped me complete Other Asian this survey Native Hawaiian Guamanian or Chamorro END 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.
What is your race? You may select one or more categories. White Black or African American American Indian or Alaska Native Asian 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? Check 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
HSSC-Patient-Survey-English.docx