Form 009_Sickle Cell_Cl 009_Sickle Cell_Cl 009_Sickle Cell_Client and Fam Comm Form

OMB Number: xxxx-xxxx

Expiration Date:

Public Burden Statement: 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.  The OMB control number for this project is 0915-xxxx.  Public reporting burden for this collection of information is estimated to average 30 minutes per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

Section G: CLIENT FAMILY COMMUNICATION
37. For Caregivers of clients under age 18	37. For Clients 18 years or older
The following questions pertain to clients under the age of 18 years and their caregivers. (Language categories provided below.) What is the primary spoken language in the client’s home? _________________________ If English is not your primary language do you require a translator for medical services/medical information? Yes No Not Applicable What, if any, is the secondary spoken language? ________________________ What language is the client/caregiver most comfortable reading? Client: . Don’t Know Not Applicable Caregiver: . What is highest level of education attained? Caregiver: . Don’t Know Not Applicable Continue to questions 38 and 39	The following questions pertain to the client 18 years of age or older. (Language categories provided below.) What is the primary spoken language in the client’s home? ____________________________ If English is not your primary language do you require a translator for medical services/medical information? Yes No Not Applicable What, if any, is the secondary spoken language? _________________________ What language are you most comfortable reading? _______________________________ What is the highest level of education you attained? _______________________________ Continue to questions 38 and 39
*Language categories: American Sign Language, Arabic, Chinese, Haitian Creole, Igbo, Korean, Somali, Spanish, Vietnamese, Yoruba or please provide any other language not listed.
Is the client of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican American Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin- Print, for example, Argentinean, Colombian, Dominican, Nicaragua, Salvadoran, Spaniard, and so on. What is the client’s race? Mark (X) one or more boxes. White Black or African American American Indian or Alaska Native- Print name of enrolled or principal tribe. _____________________________________________________________________ Asian Indian Japanese Native Hawaiian Chinese Korean Guamanian or Chamorro Filipino Vietnamese Samoan Other Asian- Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. ______________________________________________________________________ Other Pacific Islander- Print race, for example, Fijian, Tongan, and so on. ______________________________________________________________________ Some other race. Print race. _______________________________________________________________________