Health Equity and Inclusion Perception Survey

Health Equity and Inclusion Perception Survey
Share your experiences and perceptions to help us improve equity and inclusion in health-related settings.
What is your age group?*
What is your gender identity?*
FemaleMaleNon-binary/Third genderPrefer not to sayPrefer to self-describe
Which of the following best describes your race or ethnicity?*
AsianBlack or African AmericanHispanic or LatinoNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhitePrefer not to sayOther
How would you rate your overall experience with equity and inclusion in your health care setting?*

Please indicate your level of agreement with the following statements:*

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel respected by health care staff regardless of my identity.
My cultural background is considered in my care.
I have equal access to health care services.
I am provided with information in a way I understand.
I feel safe expressing my needs and concerns.

Have you ever experienced or witnessed discrimination in a health care setting?*
YesNoPrefer not to say
If yes, please briefly describe the situation (optional):
How confident are you that your health care provider addresses your needs without bias?*
Very confidentSomewhat confidentNeutralSomewhat unconfidentNot at all confident
What improvements would you like to see regarding equity and inclusion in health care?
Do you have any additional comments or suggestions?
Should be Empty: