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?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or above
What is your gender identity?
*
Female
Male
Non-binary/Third gender
Prefer not to say
Prefer to self-describe
Which of the following best describes your race or ethnicity?
*
Asian
Black or African American
Hispanic or Latino
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Other
How would you rate your overall experience with equity and inclusion in your health care setting?
*
1
2
3
4
5
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.
1
2
3
4
5
My cultural background is considered in my care.
6
7
8
9
10
I have equal access to health care services.
11
12
13
14
15
I am provided with information in a way I understand.
16
17
18
19
20
I feel safe expressing my needs and concerns.
21
22
23
24
25
Have you ever experienced or witnessed discrimination in a health care setting?
*
Yes
No
Prefer 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 confident
Somewhat confident
Neutral
Somewhat unconfident
Not 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?
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