Cultural Competency Questionnaire Logging
Welcome
  • This survey has been adapted with permission from the Clinical Cultural Competency Questionnaire (CCCQ) developed by Robert C. Like, MD, MS, Professor and Director of the Center for Healthy Families and Cultural Diversity, UMDNJ-Robert Wood Johnson Medical School
Survey - Demographic Characteristics
Year Taken:
Time of Survey:
ID Code:
*
  • {Note the ID Code is your Date of Birth and Mother's Maiden Name (ex 010164brown)}
1. Birth Date (MM/DD/YY):
2. Gender:
3. Race/Ethnicity:
4. Visited/lived outside US?:
If Yes, please specify
5. Speak other than English?:
If Yes, please specify
Survey - Knowledge
  • How KNOWLEDGEABLE are you about each of the following subject areas? (select one)
  • 1. Demographics of diverse racial and ethnic groups:
.
  • 2. Sociocultural characteristics of diverse racial and ethnic groups:
.
  • 3. Health risks experienced by diverse racial and ethnic groups:
.
  • 4. Health disparities experienced by diverse racial and ethnic groups:
.
  • 5. Sociocultural issues in:
  • ---- a. Health Promotion/Disease Prevention ----
.
  • ---- b. Reproductive Health/Pregnancy ----
.
  • ---- c. Child Health ----
.
  • ---- d. Adolescent Health ----
.
  • ---- e. Adult Health ----
.
  • ---- f. Geriatrics ----
.
  • ---- g. Women's Health ----
.
  • 6. Ethnopharmacology (i.e., variations in medication responses in diverse ethnic populations):
.
  • 7. Different Healing Traditions (e.g., Ayurvedic Medicine, Traditional Chinese Medicine):
.
  • 8. Historical and contemporary impact of racism, bias, prejudice and discrimination in health care experienced by various population groups in the United States:
.
  • 9. Office for Civil Rights August 30, 2000 Policy Guidance on the Title VI Prohibition Against National Origin Discrimination as it Affects Person with Limited English Proficiency:
.
  • 10. Office of Minority Health's National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care:
.
Survey - Skills
  • How SKILLED are you in dealing with sociocultural issues in the following areas of patience care? (select one)
  • 1. Greeting patients in a culturally sensitive manner:
.
  • 2. Eliciting the patient's perspective about health and illness (e.g., its etiology, name, treament, course, prognosis):
.
  • 3. Eliciting information about use of folk remedies and/or other alternative healing modalities:
.
  • 4. Eliciting information about use of folk healers and/or other alternative practitioners:
.
  • 5. Performing a culturally sensitive physical examination:
.
  • 6. Prescribing/negotiating a culturally sensitive treatment plan:
.
  • 7. Providing culturally sensitive patient education and counseling:
.
  • 8. Providing culturally sensitive clinical preventive services:
.
  • 9. Asessing health literacy:
.
  • 10. Working with medical interpreters:
.
  • 11. Dealing with cross-cultural conflicts relating to diagnosis or treatment:
.
  • 12. Dealing with cross-cultural adherence/compliance problems:
.
  • 13. Dealing with cross-cultural ethical conflicts:
.
  • 14. Apologizing for cross-cultural misunderstandings or errors:
.
Survey - Encounters/Situations
  • How COMFORTABLE do you feel in dealing with the following cross-cultural encounters or situations? (select one)
  • 1. Caring for patients from culturally diverse backgrounds:
.
  • 2. Caring for patients with limited English proficiency:
.
  • 3. Caring for a patient who insists on using or seeking folk healers or alternative therapies:
.
  • 4. Identifying beliefs that are not expressed by a patient or caregiver but might interfere with the treatment regimen:
.
  • 5. Being attentive to nonverbal cues or the use of culturally specific gestures that might have different meanings in different cultures:
.
  • 6. Interpreting different cultural expressions of pain, distress, and suffering:
.
  • 7. Advising a patient to change behaviors or practices related to cultural beliefs that impair one's health:
.
  • 8. Speaking in an indirect rather than a direct way to a patient about his/her illness if this is more culturally appropriate:
.
  • 9. Working with health care professionals from culturally diverse backgrounds:
.
  • 10. Working with a colleague who makes derogatory remarks about patients from a particular ethnic group:
.
  • 11. Treating a patient who makes derogatory comments about your racial or ethnic background:
.
Survey - Attitudes
  • 1. How IMPORTANT are each of the following factors in contributing to health disparities? (select one)
  • ---- a. Genetics ----
.
  • ---- b. Lifestyle ----
.
  • ---- c. Environment ----
.
  • ---- d. Poverty ----
.
  • ---- e. Educational Status ----
.
  • ---- f. Illiteracy ----
.
  • ---- g. Ageism ----
.
  • ---- h. Sexism ----
.
  • ---- i. Racism ----
.
  • ---- j. Classism ----
.
  • ---- k. Ableism ----
.
  • ---- l. Homophobia ----
.
  • ---- m. Other ----
.
Please Specify
  • 2. How IMPORTANT do you believe sociocultural issues are in your interactiions with: (select one)
  • ---- a. Patients? ----
.
  • ---- b. Health Professional Colleagues? ----
.
  • ---- c. Staff? ----
.
  • 3. How AWARE are you of your own: (select one)
  • ---- a. Racial, ethnic, or cultural identity? ----
.
  • ---- b. Racial, ethnic, or cultural stereotypes? ----
.
  • ---- c. Biases and prejudices? ----
.
  • 4. How IMPORTANT do you feel it is for health professionals to receive training in cultural diversity and/or multiculural health care? (select one)
.
Survey - Education and Training
  • 1. HOW MUCH TRAINING in cultural diversity have you previously had: (select one)
  • ---- a. In College? ----
.
  • ---- b. In a Work Setting? ----
.
  • 2. Have you ever visited and made use fo the following websites:
  • ---- a. Better Diabetes Care http://www.betterdiabetescare.nih.gov/ISSUESculturalcomptencypractices.htm
YES or NO
  • ---- b. Resources for Cross Cultural Health Care? http://www.diversityrx.org
YES or NO
  • ---- c. Office of Minority Health's National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care? http://www.omhrc.gov/CLAS
YES or NO
  • 3. What are some potential challenges to integrating training about culturally competent health care organizations and clinical practice?
Comments:
  • 4. Please offer any further comments or suggestions that you may have.
Comments:
Thank You!
  • Thank you very much!
 
Copyright © 2009 Commonwealth of Kentucky
All rights reserved.
CHFS Application Name