Assessment of Organizational Cultural Competence Our program is undertaking an effort to identify our organizations strengths and needs for

further training and program development to become a more culturally competent organization. As a member of this program, your input into the assessment of our organizations cultural competence is important. Your responses will be held in strictest confidence and will be anonymous. The results of this survey will be utilized in aggregate and summary form only. f you have !uestions about the assessment of organizational cultural competence, please contact "name of the individual who will be coordinating this effort# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. %hen you have completed the assessment, place it in "mail&bo' or location# $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$. Thank you for your assistance in this most important effort toward becoming a culturally competent program. Please check below which of the following BEST describes your the organization# C$EC% O&'( O&E Administration *upport *ervices Advisory -oard (linical services +ducation,training Technical assistance,(onsultant A!O" function in )esearch *tudent,Trainee

(ommunity,continuing education Other .lease specify/ Please indicate the length of in)ol)ement with this organization* 0ess than 1 year 1 to 2 years 3ore than 2 years Please check the O&E answer that BEST +ESC",BES your response to each of the statements# A# Organization 1. (ultural competence is included in the mission statement, policies, and procedures. 4. A committee,task force,program area addresses issues of cultural competence. 5. .artnerships with representatives of ethnic communities actively incorporate their knowledge and e'perience in organizational planning. 6. The organization supports involvement with and,or utilization of the resources of regional and,or national forums that (ES &O +on-t %now

promote cultural competence.

B# Administration 1. .ersonnel recruitment, hiring, and retention practices reflect the goal to achieve ethnic diversity and cultural competence. 4. )esources are in place to support initial and ongoing training for personnel to develop cultural competence. 5. .osition descriptions and personnel performance measures include skills related to cultural competence. 6. .articipants for all advisory committees and councils are recruited and supported to ensure the diverse cultural representation of the organizations geographic area. 2. .ersonnel are respected and supported for their desire to honor and participate in cultural celebrations. 7. 8iscal resources are available to support translation and interpretation services. C# Clinical Ser)ices , PO"TA&T* ,f your organization does not pro)ide these ser)ices. please check here and proceed to the ne/t Section# 00000 1. (linical services are routinely and systematically reviewed for methods, strategies, and ways of serving consumers and their families in culturally competent ways. 4. (ultural bias of assessment tools is considered when interpreting of the results and making recommendations.

Almost Always

Often Sometimes

Almost +on-t &e)er %now

Almost Always

Often Sometimes

Almost +on-t &e)er %now

5. Translation and interpretation assistance is available 9 utilized when needed. 6. 8orms of communication "reports, appointment notices, telephone message greetings, etc.# are culturally and linguistically appropriate for the populations served. 2. .ictures, posters, printed materials and toys reflect the culture and ethnic backgrounds of the consumers and families served. 7. %hen food is discussed or used in assessment or treatment the cultural and ethnic background of the consumer and family is considered. Almost +# "esearch and Program Always E)aluation* , PO"TA&T* ,f your organization is not in)ol)ed in these acti)ities. please check here and proceed to the ne/t Section# 00000 1. nput on research priorities is sought from consumers and,or their families representing diverse cultures. 4. )esearch pro:ects include sub:ects of diverse cultures representative of the targeted research population. 5. The researchers include members of the racial,ethnic groups to be studied and,or individuals who have ac!uired knowledge and skills to work with sub:ects from those specific groups. Almost +on-t &e)er %now

Often Sometimes

6. (onsumers and families representing diverse cultures provide input regarding the design, methods, and outcome measures of research and program evaluation pro:ects.

E# Technical Assistance1Consultation , PO"TA&T* ,f your organization is not in)ol)ed in these acti)ities. please check here and proceed to the ne/t Section# 00000 1. Technical assistance,(onsultation activities are routinely and systematically reviewed for methods, strategies, and ways of serving communities in culturally competent ways. 4. %hen assessing the need for technical assistance,consultation in communities, input from members reflecting the diverse cultural make&up of these communities is sought and utilized. 5. +fforts are made to involve consultants who have knowledge of and e'perience with the cultural group re!uesting the technical assistance,consultation. 6. +valuation from the recipients of technical assistance,consultation activities includes components of cultural competence.

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+on-t %now

2# Education1Training , PO"TA&T* ,f your organization is not in)ol)ed in these acti)ities. please check here and proceed to the ne/t Section# 00000 1. Trainees,students are actively recruited from diverse cultures. 4. Trainees,students from diverse cultures are mentored. 5. )epresentatives of the diverse cultures are actively sought to participate in the planning and presentation of training activities. 6. The training curriculum and activities incorporate content for the development of cultural competence. 2. The training curriculum, materials and activities are systemically evaluated to determine if they achieve cultural competence.

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+on-t %now

3# Community1Continuing Education , PO"TA&T* ,f your organization is not in)ol)ed in these acti)ities. please check here 0000000000# 1. .articipants are actively recruited from diverse cultures. 4. )epresentatives of diverse cultures are actively sought to participate in the planning and presentation of these activities. 5. The content and activities are culturally and linguistically appropriate. 6. .articipant evaluation of community,continuing education activities includes components of cultural competence.

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Often Sometimes

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+on-t %now

Adapted in part from Promoting Cultural Diversity and Cultural Competency Self Assessment Checklist for Personnel Providing Services and Support to Children with Special Health Needs and Their Families by Tawara ;. <oode, <eorgetown =niversity (hild ;evelopment (enter, and Policy rief !" #ationale for Cultural Competence in Primary Health Care, developed by +lena (ohen, (onsultant, and Tawara ;. <oode, and Policy rief $" %inguistic Competence in Primary Health Care Delivery Systems" &mplications for Policy 'akers( developed by T. <oode, *. *ockalingum, 3. -rown, and %. >ones, ?ational (enter for (ultural (ompetence, <eorgetown =niversity (hild ;evelopment (enter.

"espondent ,nformation -efore completing this !uestion, please review the statements on Assessment of ndividual (ultural (ompetence. After reflecting upon the entire survey, please describe the sub:ects or topics you would like cultural competence training in/ 4# 00000000000000000000000000000000000000000000000000000000000000000000 0 5# 00000000000000000000000000000000000000000000000000000000000000000000 0 6# 00000000000000000000000000000000000000000000000000000000000000000000 0 The data on this sheet are collected to obtain information about the survey respondents. This information will allow us to determine if all groups have been represented. Your information will not be shared with anyone in the organization. This information will not be linked to your responses on the other pages. P'EASE P"O7,+E T$E 2O''O8,&3 ,&2O" AT,O& by using a check mark# 3ender/ Age/ 8emale 1@&52 :: 3ale 57&6A Yes 2B&72 ?o Yes ?o 72C

+o you ha)e a disability9

Are you a family member of a person with a disability9

Please indicate your racial1ethnic identity using O&E of the categories below* African American,-lack American Asian .acific slander 3ultiethnic,Other .lease specify/ American ndian,?ative "including Alaskan native# Dispanic %hite, +uropean, non& Dispanic

Developed )y the A*CD 'ulticultural Council