AHRQ Race/Ethnicity Survey

Hello, is NAME OF SELECTED RESPONDENT available?

1. YES If person answering is the 'selected respondent' and the selected respondent is over age 18 go to intro. If selected respondent comes to the phone then go to intro.



2. NO Not available now SCHEDULE CALLBACK



3. NO Not available at this phone number GO TO SCREEN TO ENTER NEW PHONE NUMBER



4. Not known /wrong number CODE OUT AS WRONG NUMBER

INTERVIEWER NOTE: OK TO CALL OUT OF STATE TO COMPLETE INTERVIEW.

IF SELECTED RESPONDENT IS UNDER AGE 18 WILL WE HAVE THE NAME OF THE PARENT OR RESPONSIBLE ADULT TO ASK FOR AND THEN MODIFY THE SCRIPT? NO

________________________________________________________________________

IF PERSON ANSWERING THE PHONE ASKS FOR ADDITIONAL INFORMATION PLEASE READ:

I am calling for the New Mexico Department of Health. My name is (YOUR NAME) . We are gathering information about the health of New Mexico residents. NAME OF SELECTED RESPONDENT has been chosen TO PARTICIPATE IN A VERY SHORT HEALTH SURVEY. WHEN WOULD BE A GOOD TIME TO REACH NAME OF SELECTED RESPONDENT?

INTRO:

To the SELECTED respondent:

HELLO, I am calling for the New Mexico Department of Health. My name is (YOUR NAME). We are gathering information about the factors related to the health of New Mexico residents. You have been chosen from a group of people who were hospitalized in the last year. I would like to ask some questions that will take about 5 minutes. These questions will be used to help us evaluate the quality of our information and to improve the quality of services in New Mexico.

You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential.

Your answers will be grouped with those from other respondents. Your name will not be in any reports. Your survey may be combined with information the Department of Health has from other sources.

If you have any questions about this survey, I can provide you with a phone number to talk with the coordinator of this project.

Noell Stone, MPH
NM Department of Health
(505) 476-3584

Nicole Katz, MPH
NM Department of Health
(505) 476-3739

**IF RESPONDENT ASKS:

How did you get my name?

ANSWER:

Your name was randomly chosen from the Hospital Inpatient Discharge Database in order to collect information about the factors that affect the health of the residents of New Mexico.

Q1. Would you say that in general your health is:

Please read:

1. Excellent
2. Very good
3. Good
4. Fair
5. Poor

Do not read:

7. Don't know / Not sure
9. Refused

Q2. Are you Hispanic or Latino?

1. Yes
2. No
7. Don't know / Not sure
9. Refused

Q3. Which one or more of the following would you say is your race?

CATI NOTE: IF Q2=1 READ Q3 AS 'WHITE HISPANIC, BLACK HISPANIC, ETC.' (Check all that apply)

Please read:

1. White
2. Black or African American
3. Asian
4. Native Hawaiian or Other Pacific Islander
5. American Indian or Alaska Native
6. Other (specify)______________

Do not read:

8. No additional choices
7. Don't know / Not sure
9. Refused

CATI note: If more than one response to Q3; go to Q4. If Q3 = 5 then go to Q5. All other responses go to Q7.

Q4. Which one of these groups would you say best represents your race?

Do not read:

1. White
2. Black or African American
3. Asian
4. Native Hawaiian or Other Pacific Islander
5. American Indian or Alaska Native
6. Other (specify)______________ (FIELD SIZE=20)
7. Don't know / Not sure
9. Refused

CATI: ASK Q5 IF Q3 CONTAINS '5' OTHERWISE GO TO Q7

Q5. What is your tribal affiliations or tribal enrollment?
(check all that apply)

DO NOT READ UNLESS RESPONDENT NEEDS CHOICES

1. Apache (Jicarilla / Mescalero)
2. Navajo/Dine
3. Acoma
4. Cochiti
5. Isleta
6. Jemez
7. Laguna
8. Nambe
9. Picuris
10. Pojoaque
11. San Felipe
12. San Ildefonso
13. Ohkay Owingeh
14. Sandia
15. Santa Ana
16. Santa Clara
17. Kewa/Santo Domingo
18. Taos
19. Tesuque
20. Ysleta
21. Zia
22. Zuni
23. Other, specify___________________________
88. No Additional choices
77. Don't know/Not sure
99. Refused

CATI note: If more than one response to Q5, go to Q6. Otherwise, go to Q7.

Q6. What is your main tribe?

DO NOT READ UNLESS RESPONDENT NEEDS CHOICES

1. Apache (Jicarilla / Mescalero)
2. Navajo/Dine
3. Acoma
4. Cochiti
5. Isleta
6. Jemez
7. Laguna
8. Nambe
9. Picuris
10. Pojoaque
11. San Felipe
12. San Ildefonso
13. Ohkay Owingeh
14. Sandia
15. Santa Ana
16. Santa Clara
17. Kewa/Santo Domingo
18. Taos
19. Tesuque
20. Ysleta
21. Zia
22. Zuni
23. Other, specify___________________________
88. No Additional choices
77. Don't know/Not sure
99. Refused

Q7. How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

1. White
2. Black or African American
3. Hispanic or Latino
4. Asian
5. Native Hawaiian or Other Pacific Islander
6. American Indian or Alaska Native
8. Some other group (please specify:_____)
7. Don't know/Not sure
9. Refused

FOR CLARIFICATION: Sometimes you may identify with one racial group but others may identify you with a different racial group. For example, you may identify as White, but others see you as Native American.

Q8. When you were admitted to the hospital, were you asked to identify your race, ethnicity and/or tribal affiliation?

1. Yes (Go to Q9)
2. No (Go to Q10)
7. Don't know / Not sure (Go to Q10)
9. Refused (Go to Q10)

Q9. Did somebody ask you your race/ethnicity and/or tribal affiliation or did you write it on a form?

1. Verbally Asked
2. Paper/Written Form
3. Other _________________
7. Don't Know / Not Sure
9. Refused

Q10. What is the highest grade or year of school you completed?

___________________________________________________________

Read only if necessary:

1. Never attended school or only attended kindergarten
2. Grades 1 through 8 (Elementary)
3. Grades 9 through 11 (Some high school)
4. Grade 12 or GED (High school graduate)
5. College 1 year to 3 years (Some college or technical school)
6. College 4 years or more (College graduate)

Do not read:

9. Refused

Q11. Is your annual household income from all sources—

If respondent refuses at ANY income level, code 9 (Refused)

Read only if necessary:

0 4 Less than $25,000 If "no," ask 05; if "yes," ask 03
($20,000 to less than $25,000)

0 3 Less than $20,000 If "no," code 04; if "yes," ask 02
($15,000 to less than $20,000)

0 2 Less than $15,000 If "no," code 03; if "yes," ask 01
($10,000 to less than $15,000)

0 1 Less than $10,000 If "no," code 02

0 5 Less than $35,000 If "no," ask 06
($25,000 to less than $35,000)

0 6 Less than $50,000 If "no," ask 07
($35,000 to less than $50,000)

0 7 Less than $75,000 If "no," code 08
($50,000 to less than $75,000)

0 8 $75,000 or more

Do not read:

7 Don't know / Not sure
9 Refused

I would like to remind you that this is a confidential survey and your name will not be in any reports or linked to your responses.

Q12. In which country were you born?

_____________________________________________________ (FIELD SIZE=20)

CLOSING:

That is my last question. The information that you provided will be very useful to the New Mexico Department of Health in providing services to the people of New Mexico. Thank you very much for your time and cooperation.