REaL Data

The Physicians, Nurse Practitioners and Staff at Kids First Pediatrics want to make sure that all our patients get the best care possible. It is important to us that any disparities in healthcare are addressed.

As part of the Lurie Children’s Physician Partners network, we are able to provide our patients with access to numerous specialists in the Chicagoland area. Lurie Children’s has tasked each of its physician practices with obtaining REaL data (Race, Ethnicity and Language) to ensure that every person of every background receives the highest quality of care. It is also important that we know your spoken language so that you and your child’s health care team here at Kids First Pediatrics can have good communication.

We will keep this information private and will update it in your child’s medical record. Your answers are confidential. You need not answer any question you prefer not to answer.

Name

1. Are you of Hispanic, Latino, or Spanish origin? (Mark ONE box.)

YES

No, not Hispanic, Latino, or Spanish origin

2. What is your race? (Mark one or more boxes.)

White/Caucasian

Black/African American

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Some other race

Prefer not to answer

If Some Other Race, please specify.

3. IF MORE THAN ONE RACE (Question #2) IS CHECKED: Do you identify with any one race in particular?

Yes

If yes, specify.

4. What language do you feel most comfortable using with your healthcare providers and staff?

English

Spanish

Another Language

If another language, specify.

Your information will be encrypted.