Patient Demographic Information Form

Attachment 5 Staff Project ID: __________

Clinic Project ID: __________

Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX

Patient Demographic Information

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Patient Demographic Information

Date of Birth (month/year)

_____/ ______

Sex: (check all that apply)

□ Male

□ Female

□ Transgender

Race (check all that apply)

□ White

□ Black/African American

□ Asian

□ Native Hawaiian/Pacific Islander

□ American Indian/Alaska Native

□ Other: __________

Ethnicity

□ Hispanic/Latino

□ Not Hispanic/Latino

□ Unknown

Education level

□ less than high school

□ high school only

□ some college

□ college or above

□ Unknown

Number of people in household: _________ □ Unknown

Annual household income

□ < $15,000

□ ≥ $15,000 - < $30,000

□ ≥ $30,000

□ Unknown

Housing status

□ currently homeless

□ not currently, but homeless in the past 12 months

□ homeless previously, but not homeless in the past 12 months

□ Never homeless

□ Unknown

Employment status (check all that apply)

□ unemployed

□ employed

□ disabled

□ student

□ retired

□ Unknown

If patient is employed, is he/she employed part time or full time?

□ N/A

□ part time

□ full time

□ Unknown

Medical Insurance status (check all that apply)

□ Private insurance

□ Medicaid

□ Medicare

□ Ryan White/ADAP

□ uninsured

□ Unknown