Form No Number No Number Reactions to Race Module Cognitive Test

Attachment 1.

Reactions to Race Module Cognitive Test

OMB no. 0920-0237

Expires: 11/30/2009

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Now I will ask how other people identify you and treat you.

1. How do other people usually classify you in this country? Would you say White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?

1 White

2 Black or African American

3 Hispanic or Latino

4 Asian

5 Native Hawaiian or Other Pacific Islander

6 American Indian or Alaska Native

8 Some other group (please specify) _________________________

7 Don’t know / Not sure

9 Refused

2. How often do you think about your race? Would you say never, once a year, once a

month, once a week, once a day, once an hour, or constantly?

1 Never

2 Once a year

3 Once a month

4 Once a week

5 Once a day

6 Once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused

3. Within the past 12 months at work, do you feel you were treated worse than other races, the same as other races, better than other races, or worse than some races but better than others?

1 Worse than other races

2 The same as other races

3 Better than other races

4 Worse than some races, better than others

5 Only encountered people of the same race

7 Don’t know / Not sure

9 Refused

4. Within the past 12 months, when seeking health care, do you feel your experiences were worse than other races, the same as other races, better than other races, or worse than some races but better than others?

1 Worse than other races

2 The same as other races

3 Better than other races

4 Worse than some races, better than others

5 Only encountered people of the same race

6 No health care in past 12 months

7 Don’t know / Not sure

9 Refused

5. Within the past 12 months on average, how often have you experienced any physical symptoms, for example a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?

1 Never

2 No more than once a year

3 At least once a month

4 At least once a week

5 At least once a day

6 At least once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused

6. Within the past 12 months on average, how often have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

1 Never

2 No more than once a year

3 At least once a month

4 At least once a week

5 At least once a day

6 At least once an hour

8 Constantly

7 Don’t know / Not sure

9 Refused