Pullman Family Medicine
915 NE Valley Rd
Pullman, WA 99163
Phone: (509) 332-3548
Fax: (509) 332-5253

Federal Race and Ethnicity Data Collection Sheet


Fill-out the form below and then print it out. Your information will not be saved or sent.

In accordance with the American Recovery and Reinvestment Act of 2009 and the Health Information Technology for Economic and Clinical Health Act (HITECH ACT), Pullman Family Medicine will now be maintaining and collecting Federal data on race and ethnicity.

The categories below are the minimum categories for data on race and ethnicity in accordance with the federal government guidelines.  The categories are social-political constructs that should not be interpreted as being scientific or anthropological in nature.  The standards have been developed to provide a common language for uniformity and comparability in the collection and use of data on race and ethnicity by the Federal government.   The categorical designations below will not impact the quality of care or any clinical or administrative practices at Pullman Family Medicine; they are only for the purposes of federal data collection.

Please include the patients name and date of birth and mark ONE of the categories listed below. A non-designation will be recorded as “Patient Declined” for record keeping purposes:

Patient Name:
Patient Date of Birth:
Race: (Choose One)
  • American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
  • A person having origins in any of the original peoples in the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
  • Black or African American. A person having origins in any of the black ethnic groups of Africa.
  • Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.
  • Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
  • A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
  • Patient Declined