ADDITIONAL INFORMATION REQUIRED FOR NEW STATE OF OREGON REPORTING REQUIREMENTS

Point of Origin  (where the patient will be coming to the surgery center from) Must Check one:

_____ Home    (patient's home, retirement home, correctional facility, non-medical group, etc.)
_____ Skilled nursing facility
_____ Other health care facility

Ethnicity Must Check one:

_____ Hispanic or Latino   (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race)
_____ Non-Hispanic or Latino
_____ Patient Refused
_____ Unknown   (Only use when patient or caregiver is unable to provide answer)

Race   Must Check one:

_____ American Indian or Alaska Native   ( A person having origins in any of the original peoples of North and South America)
_____ Asian
_____ Black or African American    (A person having origins in any of the black racial groups of Africa)
_____ Native Hawaiian or Pacific Islander    (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands)
_____ White    (A person having origins in any of the original peoples of Europe, the Middle East or North Africa)
_____ Patient Refused
_____ Unknown     (Only use when patient or caregiver is unable to provide answer)