To meet Washington State Department of Health requirements and to provide equitable care to all patients, Mid-Valley Hospital is required to ask questions that may be new to you.
You are not required to answer these questions.
While reporting demographic data to the state is mandatory for hospitals, patient participation is voluntary.
YOU GET TO DECIDE: It’s up to you whether you answer these questions. We must ask these questions to be compliant with Washington State law (HB 1272) but you are not required to answer them. For questions you do not wish to answer, you can reply with a Decline/Pass answer.
Your answers are voluntary.
We want everyone to feel safe answering questions and declining to answer questions.
WHY WE ASK: Your answers to these questions will assist in identifying and addressing health disparities in Washington State.
If you believe Washington State’s Engrossed Second Substitute House Bill (E2SHB) 1272 (WAC 246-455-025) violates your rights or you have specific questions regarding this law, please contact your legislative representative or Washington State Department of Health at CHARSGeneral@doh.wa.gov.
If you believe Mid-Valley Hospital is noncompliant with this law or your rights have been violated due to discriminatory action or bias, please contact the Mid-Valley Hospital Compliance Officer at 509-861-2443.
BELOW ARE SOME QUESTIONS YOU WILL BE ASKED DURING SCHEDULING/REGISTRATION:
What is your legal sex?
Female – Male – Gender X – Unknown
What was your sex at birth?
Female – Intersex – Male – Unknown
What is your race?
Afghan
Afro-Caribbean Alaskan
Native Afghan
Afro-Caribbean Alaskan
Native American Indian
Arab
Asian
Bamar/Burman/Burmese
Bangladeshi Bhutanese
Black or African Amer-ican
Central American Cham
Chicano/a or Chicanx
Chinese
Congolese
Cuban
Dominican
Egyptian
Eritrean
Ethiopian
Fijian
Taiwanese
Thai
Tongan
Hispanic ethnicity? No –
Non Hispanic Patient
declines to answer
Unable to collect information
What is your language?
Aguacateco
Amharic
Arabic
Armenian
Awakatek
Bangla
Bengali
Bosnian
Bulgarian
Burmese
Cantonese Chalchiteco
Chamorro
Chinese
Chuukese
Creole Czechoslovakian
Dari
Dutch
English
Farsi (Persian)
Fijian
Filipino/Pilipino
Finnish
Flemish
Marshallese
Mienh
Mixteco
Moldovan
Nahuatl
Nepali
Norwegian
Disabilities?
Brain Injury
Chronic Medical
Condition Developmental
Disability Hearing impaired
Intellectual Disability
Filipino
First Nations
Guamanian or Chamorro
Hmong/Mong
Indian
Indigenous-Latino/a or
Indigenous-Latinx
Indonesian
Iranian
Iraqi
Japanese
Jordanian
Karen
Kenyan
Khmer/Cambodian Korean
Kuwaiti
Lao
Lebanese
Malaysian
Marshallese
Ugandan
Ukrainian
Unknown to Patient
Unknown to patient
Yes – Another Hispanic,
Latino or Spanish origin Yes, Cuban
French
German
Greek
Gujarati
Haitian Creole
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indian
Italian
Other
Other Communication
Oromo
Marathi
Method
Pashto
Somali
Spanish/Castilian Swahili/
Kiswahili Swedish
Tagalog
Tamil
Telugu
Thai
Tigrinya
Tongan
Trique
Turkish
Ukrainian
Mental Health Disability
Neurocognitive Disability Not
Applicable
(no disability or condition)
Mestizo
Mexican/Mexican American
Middle Eastern
Mien
Moroccan
Native Hawaiian
Nepalese
North African
Oromo
Other race
Pacific Islander Pakistani
Patient declined to answer
Puerto Rican
Romanian/Rumanian Russian
Samoan
Saudi Arabian
Somali
South African
South American
Syrian
Vietnamese
White or Caucasian Yemeni
Yes – Mexican, Mexican
American, Chicano/a Yes –
Puerto Rican
Japanese
Kanjobal
Karen
Khmer/Cambodian K’iche’
Kinyarwanda
Korean
Kosraean
Kurdish
Kurindi (Rundi)
Lakota Sioux
Lao
Lingala
Lithuanian
Malay
Mam
Mandarin
Patient declined to respond
Polish
Portuguese
Portuguese (Brazilian) Punjabi
Puyallup
Romanian/Rumanian Russian
Salish
Samoan
Sign Languages
Unknown to Patient Urdu
Vietnamese
Yakima
Zapotec
Patient declined to respond
Physical Disability Unknown
Vision Impaired Wheelchair