IMMEDIATE POST TEST

ID NUMBER_________________________

New Mexico logo

Today's Date __________________

Hospital__________________________

Gender______________________

Age Range:     18-24      25-34      35-44      45-54      55-64      65-74      75+

DEMOGRAPHICS

1. What is your position in the hospital?
   a. Registration Staff
   b. Nurse
   c. Physician
   d. Other-Plese List _____________________



2. What is your ethnicity?
   a. Hispanic/Latino
   b. Non-Hispanic/Non-Latino
   c. Do not know
   d. Declined



3. What is your race? Please circle all that apply.
   a. White
   b. Black/African American
   c. Alaska Native/Native American
   d. Asian/Pacific Islander
   e. Do not know
   f. Declined



4. What is your tribal identification? Please circle all that apply.
   a. Jicarilla Apache Nation
   b. Mescalero Apache Nation
   c. Acoma Pueblo
   d. Cochiti Pueblo
   e. Isleta Pueblo
   f. Jemez Pueblo
   g. Laguna Pueblo
   h. Nambe Pueblo
   i. Picuris Pueblo
   j. Pojoaque Pueblo
   k. Ohkay Owingeh Pueblo
   l. Sandia Pueblo
   m. Santa Ana Pueblo
   n. Santa Clara Pueblo
   o. Kewa/Santo Domingo Pueblo
   p. Taos Pueblo
   q. Tesuque Pueblo
   r. Zia Pueblo
   s. Zuni Pueblo
   t. New Mexico Navajo Nation
   u. Other Tribal Affiliation- Please List ______________
   v. Unknown
   w. No tribal affiliation



5. What is your main tribe?
   a. Jicarilla Apache Nation
   b. Mescalero Apache Nation
   c. Acoma Pueblo
   d. Cochiti Pueblo
   e. Isleta Pueblo
   f. Jemez Pueblo
   g. Laguna Pueblo
   h. Nambe Pueblo
   i. Picuris Pueblo
   j. Pojoaque Pueblo
   k. Ohkay Owingeh Pueblo
   l. Sandia Pueblo
   m. Santa Ana Pueblo
   n. Santa Clara Pueblo v o. Kewa/Santo Domingo Pueblo
   p. Taos Pueblo
   q. Tesuque Pueblo
   r. Zia Pueblo
   s. Zuni Pueblo
   t. New Mexico Navajo Nation
   u. Other Tribal Affiliation- Please List ______________
   v. Unknown
   w. No tribal affiliation

ATTITUDES:

Please circle the attitude which most identifies with your feelings towards each statement.

1-Strongly Agree; 2-Agree; 3-Neutral; 4-Disagree; 5-Strongly Disagree

I think race/ethnicity is an important aspect of healthcare	1 2 3 4 5
I think a person's race/ethnicity can affect their quality of healthcare	1 2 3 4 5
To determine a patient's race/ethnicity I observe the patient's physical characteristics.	1 2 3 4 5
I think talking about race/ethnicity is uncomfortable	1 2 3 4 5
I can tell a person's race/ethnicity by looking at them	1 2 3 4 5
I understand the meaning of the term "race"	1 2 3 4 5
I understand the meaning of the term "ethnicity"	1 2 3 4 5
I understand the meaning of the term "tribal affiliation"	1 2 3 4 5
I think my role in race/ethnicity/ tribal affiliation data collection is important	1 2 3 4 5
The way I collect race/ethnicity/tribal affiliation data will change because of the training I received today	1 2 3 4 5
I can explain the importance of collecting race/ethnicity/tribal affiliation data to patients as a result of the training	1 2 3 4 5

Adapted from Data Collection on the Race, Ethnicity and Primary Language of Hospital Patients Survey by Health Insight New Mexico and the Robert Wood Johnson Foundation's Race, Ethnicity and Language of Patients: Hospital Practices Regarding Collection of Information to Address Disparities in Health Care