Survey Text

2021 2016 2011 2006
2020 2015 2010 2005
2019 2014 2009 2004
2018 2013 2008 2003
2017 2012 2007 2002
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2021

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2017
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2016
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2015
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2014
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2013
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2012
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2011
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2010
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2009
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2008
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2007
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2006
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2005
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2004
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2003
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------

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2002
Survey form view entire document:  text  image
AC19
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
----------------------------------------------------
IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO AC20
----------------------------------------------------