Data Collection Survey Templates

Boston Public Health Commission

These two survey templates were developed by the Boston Public Health Commission to aid hospitals, health centers, and community organizations in collecting information by race, ethnicity, preferred language, and highest level of education from their patients. There are two toolkit templates. Template A collects information for Latino/Hispanic individuals within the race category and Template B collects Latino/Hispanic as a separate question. Though these surveys were developed for health care organizations in Boston, they can be adapted to meet the needs of any health care organization.


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