Client Survey of Staff/Site Cultural Competence
This checklist is intended to assess your clients’ perception of your staff and site’s level of cultural competence.
select A, B, C or D for each item listed below.
A = I strongly agree
B = I somewhat agree
C = I somewhat disagree
D = I strongly disagree
E = Not applicable
_____ 1. My home visitor is interested in getting to know me and my children as individuals.
_____ 2. My home visitor regards me in a friendly, informal, but respectful manner.
_____ 3. My home visitor avoids imposing childcare values of their own that may conflict or be inconsistent with those of my culture or ethnic orientation.
_____ 4. My home visitor accepts me and my family as the ultimate decision makers for the well-being of my children and the services that we receive.
_____ 5. My home visitor never uses racial/ethnic slurs or stereotypes when referring to cultural groups.
_____ 6. My home visitor understands that my family has many other exciting and challenging events occurring in our lives, other than the content of our work together.
_____ 7. My home visitor understands and respects my family’s expectations and time-lime for children acquiring toileting, dressing, feeding, and other self help skills.
_____ 8. My home visitor understands and accepts that my family may be defined differently than in other cultures (e.g. extended family members, kin, godparents).
_____ 9. My home visitor understands that my approach to disciplining children may be influenced by my cultural background and beliefs.
_____ 10. My home visitor accepts that my religious and other beliefs may play an
important role in how my family makes decisions about childcare.
_____ 11. My home visitor accepts and respects my customs and beliefs about food, its value, preparation, and use.
_____ 12. My home visitor accepts and respects that the male-female roles in my family may vary from different cultures (e.g. who makes major decisions for the family, play and social interactions expected of male and female children).
_____ 13. My home visitor accepts and respects that the inter-generational roles in my family may vary from different cultures.
_____ 14. My home visitor and/or HFA site displays pictures, posters and other materials that reflect my culture and ethnic background.
_____ 15. The videos, films and other media resources for health education that my FSW uses reflect the culture of my family.
_____ 16. The letters, brochures, or notices that I receive from my HFA site are written in my language of origin.
_____ 17. The written materials that I receive from my HFA site are respectful and relevant when explaining their services.
Yes _____ No _____ 18. Is your primarily language other than English?
If Yes, (If No, go to question #23.)
_____ 19. My home visitor is fluent, or uses key words, in my language so that I am better able to communicate with them.
_____ 20. My home visitor uses visual aids, gestures, and physical prompts in interactions with me and my children to enhance our communication.
_____ 21. My HFA site uses bilingual staff or trained volunteers to serve as interpreters during assessment, meetings, or other events.
_____ 22. I generally feel understood when speaking to my home visitor, and that we communicate well.
23. I would like to see my home visitor/HFA site do the following to increase their level of cultural competence with me and my family:
______
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