Race Definitions OMB American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. *OMB-Mod: This symbol indicates a modification we have made to the OMB recommendations © 2007 by the Health Research and Educational Trust

Race Definitions White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Multiracial: A person having more than one or a combination of the above origins. *OMB-Mod Declined: A person who is unwilling to choose/provide a race category or cannot identify him/herself with one of the listed races. *OMB-Mod Unavailable: Select this category if the patient is unable to physically respond, there is no available family member or caregiver to respond for the patient, or if for any reason, the demographic portion of the medical record cannot be completed. Hospital systems may call this field “Unknown’, “Unable to Complete”, or “Other.” *OMB-Mod *OMB-Mod: This symbol indicates a modification we have made to the OMB recommendations © 2007 by the Health Research and Educational Trust

Ethnicity Definitions OMB Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Non-Hispanic or Latino: Patient is not of Hispanic or Latino ethnicity. Declined: A person who is unwilling to provide an answer to the question of Hispanic or Latino ethnicity. *OMB-Mod Unavailable: Select this category if the patient is unable to physically respond, there is no available family member or caregiver to respond for the patient, or if for any reason, the demographic portion of the medical record cannot be completed. Hospital systems may call this field “Unknown’, “Unable to Complete”, or “other.” *OMB-Mod *OMB-Mod: This symbol indicates a modification we have made to the OMB recommendations © 2007 by the Health Research and Educational Trust

Ethnicity Screen Now I would like you to tell me your Race and Ethnic Background. We use this to review the treatment patients receive and make sure everyone gets the highest quality of care. First, do you consider yourself Hispanic/Latino? Yes No Declined Unavailable © 2007 by the Health Research and Educational Trust

Race Screen Which category best describes your race? American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander White Multiracial Declined (this is a flag indicating that the individual did not want to answer this question—do not ask again during the same or subsequent visit) Unavailable (this is a flag indicating that the person could not answer the question. May ask the person again. © 2007 by the Health Research and Educational Trust

Using OMB (modified) Categories Without Splitting Race/Ethnicity -African American/ Black -Asian -Caucasian/White -Hispanic/Latino/White -Hispanic/Latino/Black -Hispanic/Latino/Declined -Native American -Native Hawaiian/Pacific Islander -Multiracial -Declined -Unavailable/Unknown © 2007 by the Health Research and Educational Trust