Children's Health Insurance Program (CHIP), brought to you by Geisinger Health Plan

The Health Plan is conducting a voluntary and confidential information collection campaign to gather information regarding race, ethnicity and language preference. By gathering this information from members, it will allow us to assess the cultural, ethnic, racial and linguistic needs of our members so that we may work toward improving the quality of health care by reducing racial and ethnic disparities. The collection of this data will enable us to continue improving our programs and allow our members to have better access and delivery in their health care. Click here for more information on this topic.

This data will only be used for determining appropriate educational, outreach and quality improvement initiatives and not to determine eligibility, rating or claim payment. All responses are voluntary and confidential. Please answer the questions as they apply to you.

1. Racial/Ethnic origin (please select only one):

Alaskan Native/Native American
African American or Black
Asian American
Hispanic/Latino American
Native Hawaiian or other Pacific Islander
White
Multi-racial

2. Language Preference/Spoken:

3. Language Preference/Written:

4. Highest level of school you completed (please select only one):

Middle school/Jr. High school
High school/GED
College or beyond
Other

5. Are there any other cultural and/or religious beliefs that affect your health care decisions?

No Yes

Please explain (optional):

6. What is your Zip Code?