What is the client’s race or ethnicity? Select all that apply and enter additional details in the spaces below.
RequiredotherF1
Narrative response
A prompt for a description, a selection or a short answer.
Answer categories: White – Provide details below. | German | Irish | English | Italian | Polish | French | Enter, for example, Scottish, Norwegian, Dutch, etc. ____ | Hispanic or Latino – Provide details below. | Mexican or Mexican American | Puerto Rican | Cuban | Salvadoran | Dominican | Colombian | Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. ____ | Black or African American – Provide details below. | African American | Jamaican | Haitian | Nigerian | Ethiopian | Somali | Enter, for example, Ghanaian, South African, Barbadian, etc. ____ | Asian – Provide details below. | Chinese | Filipino | Asian Indian | Vietnamese | Korean | Japanese | Enter, for example, Pakistani, Cambodian, Hmong, etc. ____ | American Indian or Alaska Native – Provide details below. | Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow | Inupiat Traditional Government, Tlingit, etc. ____ | Middle Eastern or North African – Provide details below. | Lebanese | Iranian | Egyptian | Syrian | Moroccan | Israeli | Enter, for example, Algerian, Iraqi, Kurdish, etc. ____ | Native Hawaiian or Pacific Islander – Provide details below. | Native Hawaiian | Samoan | Chamorro | Tongan | Fijian | Marshallese | Enter, for example, Palauan, Tahitian, Chuukese, etc. ____ | Race/ethnicity not captured in grantee records using detailed OMB categories. | Client/caregiver declined to provide race/ethnicity.
- Instrument
- SUPRT-A
- Target
- No target rule stated