Appendix B - TCH User Registration Form (12.2.15)

Appendix B
Think Cultural Health (TCH) User Registration Form
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Form Approved
OMB No. 0990-0407
Exp. Date XX/XX/20XX

Email address/username
Password
First name
Last name
Certificate type
Degree
State license number
ADA Membership number
License information for EMT/First Responder
Address
City
State/Province
Country
Zip Code
What is your sex?
a. Male
b. Female
Are you Hispanic, Latino/a, or of Spanish origin?
a. No, I am not of Hispanic, Latino/a, or Spanish origin
b. Yes, I am of Hispanic, Latino/a, or Spanish origin
What is your race? (Select all that apply)
a. White
b. Black or African American
c. American Indian or Alaska Native
d. Asian
e. Asian Indian
f. Chinese
i. Filipino
ii. Japanese
iii. Korean
iv. Vietnamese
v. Other Asian
g. Native Hawaiian or Other Pacific Islander
i. Guamanian or Chamorro
ii. Samoan
iii. Other Pacific Islander
What is your primary language?
a. English
b. Spanish
c. Other
How well do you speak English?
a. Very well
b. Well
c. Not well

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0990-0407 . The time required to complete this information collection is estimated to
average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer

Appendix B
Think Cultural Health (TCH) User Registration Form
d. Not at all
20. Which of these roles best applies to you? (Select 1)
a. Administrator, Health or Health Care Organization
b. Manager, Health or Health Care Organization
c. Executive, Health or Health Care Organization
d. Community Health Worker
e. Consultant
f. Disaster Personnel – Please select from the list:
i. Commissioned Corps Officer
ii. Emergency Manager
iii. EMT
iv. Paramedic
v. Volunteer
vi. Other – (if other please specify- text field)
g. Educator
h. Physician Assistant
i. Policymaker
j. Public Official (i.e., Government public official)
k. Public Health Professional
l. Mental Health Professional—Please select from the list:
i. Behavioral Analyst
ii. Licensed Professional Counselor
iii. Psychiatrist
iv. Psychologist
v. Other - (if other please specify-text field)
m. Nurse – Please select from the list:
i. Psychiatric Nurse
ii. Mental Health Nurse
iii. Home Health Nurse
iv. Hospital-Based Nurse
v. Office-Based Nurse
vi. Nurse Manager
vii. Nurse Practitioner
viii. Community Health Nurse
ix. School Nurse
x. Other (if other please specify- Text field)
n. Oral Health Professional – Please select from the list:
i. Dentist
ii. Dental Assistant
iii. Dental Hygienist
iv. Dental Specialist
v. Other - if other please specify (text field)
o. Physician – Please select from the list:
i. Community Health Physician
ii. Hospital-based Physician
iii. Office-based Physician
iv. Private practice Physician
v. Other- if other please specify (text field)

Appendix B
Think Cultural Health (TCH) User Registration Form
p. Researcher
q. Social Worker
r. Student – Please select discipline from the list:
i. Medicine
ii. Dentistry
iii. Nursing
iv. Emergency Response
v. Public Health
vi. Other- if other please specify (text field)
s. Other role – if other, please specify (text field)
21. Which of these best describes your primary place of employment?
a. Ambulatory Care Facility
b. Clinic- Office- based
c. Clinic- University- Based
d. Community-Based Organization
e. Community Health Center
f. Disaster Relief Organization
g. Educational Institution: K-12
h. Educational Institution: Higher Education (i.e., University, College)
i. Educational Institution: Professional Education
j. Faith-Based Organization
k. For-Profit Organization/Corporation
l. Government-Federal
m. Government-State
n. Government-City
o. Home Health Care Organization
p. Hospital
q. Insurance Company/Provider
r. Managed Care Organization
s. Mental Health Center
t. U.S. Military Facility
u. Non-profit Organization
v. Nursing Home
w. Private Practice
x. Public Health Department
y. Rehabilitation Center
z. Voluntary Organizations Active in Disaster (VOAD)
aa. Other - if other please specify (text field)
22. Please indicate your level of seniority in your primary place of employment.
a. Student/Trainee
b. Entry level
c. Mid-level
d. Manager
e. Executive
23. How did you hear about this e-learning program/resource?
a. Colleague
b. Communication from my professional organization [please provide the name of the
organization]

Appendix B
Think Cultural Health (TCH) User Registration Form

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c. Conference [please provide the name of the conference]
d. Email from listserv
e. Government website [please provide the name or link of the website]
f. Non-government website [please provide the name or link of the website]
g. Other email communication
h. Press announcement
i. Search engine
j. Social media
k. Telephone call
l. Training [please provide the name of the training]
m. Other [please describe]
Would you like to “Join the CLCCHC?”
a. No
b. Yes
Have you heard about the National CLAS Standards?
a. No
b. Yes
If yes, how did you hear about the National CLAS Standards?
a. Colleague
b. Communication from my professional organization [please provide the name of the
organization]
c. Conference [please provide the name of the conference]
d. Email from listserv
e. Government website [please provide the name or link of the website]
f. Non-government website [please provide the name or link of the website]
g. Other email communication
h. Press announcement
i. Search engine
j. Social media
k. Telephone call
l. Training [please provide the name of the training]
m. Other [please describe]
Can we contact you in the future about your experience using this e-learning program/resource?
a. No
b. Yes
If yes, please tell us how you would prefer to be contacted.
a. Email
b. Telephone
c. Mail