Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/20XX
ATTACHMENT 4
HHS/OCR Latino Online Survey
Hello, researchers conducting this survey would like you to answer some questions about issues affecting your family and community. At no time will you be asked for a contribution, donation or to buy anything. You will not be added to any mailing list as a result of your participation. All of your responses to the following questions are confidential. Your identity will never be connected with your responses and will never be shared with any corporate or government entities.
CODE GENDER:
Male 1
Female 2
Are you the primary caregiver for anyone, including an elderly relative or child in your household, or a neighbor or friend?
Yes 1
No 2
Don’t know/refused [only appears if skip attempted] 3
IF YES TO Q 1
Please indicate your relationship to the person who you care for? Select all that apply if you care for multiple people.
Parent 1
Aunt or Uncle 2
Grandparent 3
Child 4
Adult Child (18 years old or older) 5
Niece or nephew 6
Spouse 7
Sibling 8
Neighbor 9
Friend 10
Don’t know/refused [only appears if skip attempted] 11
Please indicate how often you visit a health care professional, either for yourself or going with someone you may care for.
More than once a month 1
About once a month 2
About once every three months 3
About once every six months 4
About once a year 5
About once every two years 6
Less than once every two years 7
Don’t know/refused [only appears if skip attempted] 8
Do you currently have any form of health insurance coverage including government sponsored health insurance like Medicare, Medicaid or TriCare?
Yes 1
No 2
Don’t know/refused [only appears if skip attempted] 3
IF YES TO Q XX = 1
Please indicate who primarily pays for your health insurance, or which government sponsored health insurance program you are covered by.
Private health insurance, paid for by an employer 1
Private health insurance, paid for personally by myself or a relative
2
Medicare 3
Medicaid 4
TriCare 5
Don’t know/refused [only appears if skip attempted] 6
Do your children currently receive government subsidized health care through the Children’s Health Insurance Program, also known as CHIP?
Yes 1
No 2
Don’t know/refused [only appears if skip attempted] 3
Thinking about where you go for medical care, does that office or clinic have someone on staff that speaks Spanish?
Yes 1
No 2
Don’t know/refused [only appears if skip attempted] 3
When you visit a medical professional such as a doctor or nurse do you usually speak with them in English or Spanish?
English 1
Spanish 2
Combination 3
Don’t know/refused [only appears if skip attempted] 4
For each of the people or organizations below, please rate your feelings on a scale from zero to one hundred with one hundred meaning a very warm, favorable feeling; zero meaning a very cold, unfavorable feeling; and fifty meaning not particularly warm or cold. You can use any number from zero to one hundred, the higher the number, the more favorable your feelings are toward that person or organization.
SHUFFLE
The Federal Government __ __
The Department of Health and Human Services __ __
SPLIT SAMPLE A
The Office for Civil Rights within the Department of Health and Human Services
__ __
SPLIT SAMPLE B
The Office for Civil Rights __ __
The government agency responsible for cracking down on discrimination by health care providers __ __
For each of the people below, please indicate how comfortable you are talking with them about your medical care on a scale from zero to ten with zero meaning you are not at all comfortable talking with them about your medical care and ten meaning you are completely comfortable talking with them about your medical care. You can use any number between zero and ten.
SHUFFLE
Your doctor or a nurse __ __
A social or case worker __ __
A professional at a community health center __ __
A family member or friend __ __
Someone who works for the Federal Government __ __
Someone working as an advocate for Latino rights __ __
Your church minister, pastor or religious leader __ __
For the list of people and groups below, please indicate whether you trust the information you receive from each about government assistance programs – do you trust the information about government assistance programs you receive from that person or group a great deal, somewhat, not too much or not at all? Government assistance programs include things like reduced school lunch, free or reduced medical care, food stamps, WIC or other programs.
Great Some Not Not
SHUFFLE Deal What Much At All DK/ref
Relatives or friends 1 2 3 4 5
Teachers or officials from your child’s school 1 2 3 4 5
A medical professional like a doctor or nurse 1 2 3 4 5
A social or case worker 1 2 3 4 5
A public service announcement or advertisements paid for by the government that appear in newspapers, on the radio or on TV 1 2 3 4 5
A celebrity 1 2 3 4 5
Your church minister, pastor or religious leader 1 2 3 4 5
Based on you and your family’s own experiences, how would you rate each of the following aspects of health care -- excellent, good, only fair, or poor?
SHUFFLE Excl Good Fair Poor DK/ref
The quality of care you or your family received 1 2 3 4 5
The ease of making an appointment to visit a health care professional
1 2 3 4 5
The affordability of the care you need 1 2 3 4 5
The respect you receive when visiting a health care professional
1 2 3 4 5
The ability of health care professionals to understand issues unique to your culture
1 2 3 4 5
There is a federal agency within the Department of Health and Human Services called the Office for Civil Rights. In your own words, what do you imagine they do? If you do not know, or are not sure what they do, just write what your best guess is. [WRITE RESPONSE]
How good of a job do you think the federal government is doing cracking down on discrimination against minorities by health care providers – do you think the federal government is doing an excellent, good, only fair or poor job cracking down on discrimination against minorities by health care providers?
Excellent 1
Good 2
Only Fair 3
Poor 4
Don’t know/refused [only appears if skip attempted] 5
For each of the following issues, please indicate if you feel it is a very serious, somewhat serious, not too serious or not at all serious problem in our society today:
Ver Smwt Not too Not
Ser Ser Ser Ser DK/ref
ALWAYS ASK FIRST
Discrimination against Latinos 1 2 3 4 5
SHUFFLE
Discrimination against Latinos in the workplace 1 2 3 4 5
Discrimination against Latinos in public schools 1 2 3 4 5
Discrimination against Latinos by health care professionals
(like doctors or nurses) 1 2 3 4 5
Discrimination against Latinos by police officers 1 2 3 4 5
Have you personally ever felt discriminated against or have you ever witnessed discrimination by a health care professional?
Yes, personally 1
Yes, witnessed 2
No 3
Don’t know/refused [only appears if skip attempted] 4
[IF YES TO Q XX]
And did you tell anyone about that discrimination?
Yes 1
No 2
Don’t know/refused [only appears if skip attempted] 3
[IF YES TO Q XX]
Please indicate from the list below who you told about the discrimination?
A friend 1
A relative 2
Another professional at the health care provider 3
The person’s supervisor 4
A government employee like a social or case worker 5
A government employee at the Department of Health and Human Services or a similar office 6
Don’t know/refused [only appears if skip attempted] 7
Now please read the following experiences that made some Latinos feel they were being discriminated against by health care professionals. For each, please indicate if you, someone in your family, or someone else you know has ever experienced this type of discrimination when receiving medical care or treatment. If no one you know has experienced this type of discrimination, or if you’re not sure, please indicate that.
Someone No
SHUFFLE You Family Know One DK/ref
Dismissive of medical concerns because of the patient’s culture
1 2 3 4 5
Dismissive of medical concerns because the patient received free or reduced cost care
1 2 3 4 5
Patient was not given all relevant tests or screenings 1 2 3 4 5
Lack of understanding or knowledge about health concerns unique to the patient’s culture
1 2 3 4 5
Assumptions were made because of the patient’s Latino background
1 2 3 4 5
Office did not have anyone on staff that spoke Spanish 1 2 3 4 5
Patient was forced to wait an excessive amount of time to receive adequate care
1 2 3 4 5
Patient was required to pay a financial deposit prior to receiving any medical treatment
1 2 3 4 5
Not enough options for quality care close to where I live 1 2 3 4 5
Patient was asked irrelevant questions about their own, or family members’ legal status
1 2 3 4 5
A child who is a US citizen was denied care because of their parent’s citizenship status
1 2 3 4 5
Whether or not you have actually experienced or witnessed discrimination please indicate how comfortable you would be talking with each of the following IF you ever were the victim of or witness to discrimination by a health care professional. Use a scale from zero to ten with zero meaning you are not at all comfortable talking with that person or group and ten meaning you are completely comfortable talking with them about discrimination you may experience or witness by a medical professional. You can use any number between zero and ten.
SHUFFLE
A friend or relative __ __
A social or case worker __ __
Another medical professional where the discrimination took place __ __
A federal government employee who can investigate the complaint
__ __
A police officer __ __
A lawyer __ __
Your church minister, pastor or religious leader __ __
Some people have said they are hesitant to speak out when they witness or experience discrimination by a health care provider. What might prevent you from speaking out if you witnessed or experienced discrimination by a health care provider? Select all that apply.
SHUFFLE
Would not know who to tell 1
Fear of losing access to health care for you and your family 2
Fear of getting in trouble with the government 3
Fear the health care provider who was the perpetrator of the discrimination would find out about your complaint 4
Fear speaking out would raise questions about your legal status 5
Other [please specify: ___ ___] 6
Would always speak out [only appears if skip attempted] 7
Don’t know/refused [only appears if skip attempted] 8
Now after reading each of the following indicate if that makes you much more likely, somewhat more likely, just a little more likely or no more likely to report a case of discrimination to a federal government official, should you ever be the victim of or witness to discrimination by a health care provider.
SHUFFLE more more more more DK
Million of Latinos are the victim of discrimination each year by a medical professional. Better reporting of discrimination will help reduce discrimination in the future
1 2 3 4 5
All complaints about discrimination by a medical professional are kept anonymous
1 2 3 4 5
The government will punish any medical professional found guilty of discrimination to the full extent of the law 1 2 3 4 5
The government will launch a full investigation into any report of discrimination by a health care professional 1 2 3 4 5
You are able to file a discrimination complaint over the phone or through the mail or email
1 2 3 4 5
You may request a private, personal meeting to file a discrimination complaint with a government official 1 2 3 4 5
You do not have to provide proof of citizenship when filing a discrimination complaint
1 2 3 4 5
Failing to report cases of discrimination allows abusers to get away with breaking the law and continue discriminating against Latinos 1 2 3 4 5
Discrimination against Latinos makes women, children and the elderly afraid and ashamed to seek the medical attention they need. Better reporting of discrimination in health care will help reduce discrimination in the future, so everyone is comfortable seeking out the care they need
1 2 3 4 5
A government resource exists where victims of discrimination by health care providers can file a formal complaint and have the government investigate and punish health care providers found guilty of discrimination 1 2 3 4 5
Cracking down on discrimination protects children here legally. Children who are US citizens have a right to quality health care, regardless of their parent’s citizenship status
1 2 3 4 5
Thank you. The remaining questions are demographic questions for classification purposes only.
Remember, we will not share your information with anyone.
How do you get most of your news about national and international issues? Please select all that apply.
SHUFFLE
Television 1
Newspapers 2
The radio 3
Magazines 4
The internet 5
Don’t know/refused [only appears if skip attempted] 6
In what language are the news programs you usually watch on television or listen to on the radio? Only Spanish, more Spanish than English, both Spanish and English equally, more English than Spanish, or only English?
Only Spanish 1
More Spanish than English 2
Both Spanish and English equally 3
More English than Spanish 4
English only 5
Don’t know/refused [only appears if skip attempted] 6
What would be the most effective way to inform you about what to do should you ever be the victim of or witness to discrimination by a health care provider?
SHUFFLE
A television commercial 1
An advertisement in the newspaper 2
A radio commercial 3
Through your doctor or health care provider 4
Something you receive in the mail 5
Another way [please specify] 6
Don’t know/refused [only appears if skip attempted] 7
And in what language would you prefer to receive information about reporting discrimination, Spanish or English?
Spanish 1
English 2
Either, both equally 3
Don’t know/refused [only appears if skip attempted] 4
Thank you for your cooperation. That completes our survey!
Code from File:
CODE AGE:
Age ___ ___
CODE COUNTRY OF ORIGIN:
Mexican 1
USA 2
Puerto Rican 3
Cuban 4
Central American 5
South American 6
Caribbean 7
Other Spanish/Latino/Hispanic 8
CODE LANGUAGE SPOKEN AT HOME:
English 1
Spanish 2
CODE LANGUAGE PROFICIENCY:
English proficient 1
Bilingual 2
Spanish proficient 3
CODE US CITIZENSHIP:
Yes, born here 1
Yes, naturalized 2
No, not a citizen 3
CODE HOURS OF SPANISH-LANGUAGE RADIO LISTENED TO EACH WEEK:
Hours ___ ___
CODE INCOME:
Less than $14,999 1
$15,000 to $29,999 2
$30,000 to $49,999 3
$50,000 to $74,999 4
$74,999 to $99,999 5
$100,000 or more 6
CODE EDUCATION:
Less than high school (no HS diploma) 1
High school graduate 2
Some college, or two year degree 3
Bachelor’s degree 4
Advanced degree 5
CODE EMPLOYMENT STATUS:
Working – paid 1
Working – self-employed 2
Not working – temporarily laid off 3
Not working – looking for work 4
Not working – retired 5
Not working – disabled 6
Not working – other 7
CODE MARITAL STATUS:
Married 1
Widowed 2
Divorced 3
Separated 4
Never married 5
Living with partner 6
CODE HOUSING TYPE:
Single family detached home 1
Single family home attached to one or more houses 2
A building with 2 or more apartments 3
A mobile home 4
Boat, RV, Van etc. 5
CODE OWNERSHP STATUS OF HOUSING:
Owned or being bought by you or someone in your household 1
Rented 2
Occupied without payment 3
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXX. The time required to complete this information collection is estimated to average two hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Missouri Statewide Survey |
| Author | Margie Omero |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |