Cultural Competency Client and Community Survey

In assessing cultural competency, each organization (or individual) is somewhere on the continuum moving toward greater cultural competence. There is no “right” or “wrong”. The purpose of this survey is to establish and maintaincultural competence.

Your survey is private and we will use the surveys to form a picture of this agency’s cultural competence.

Please answer the assessment in a manner that reflects how you see Southwest Youth & Family Services today; not how it used to be or how it will be.

This cultural competency survey asks you to circle a number to rate behaviors you have experienced in this organization. The rating scale is shown below and on the next page.

1234

Never / Sometimes / Often / Always

In addition, there is space to write any comments that would help us to understand the rating you selected.

Please complete the following:

Your Culture / Ethnicity ______

Developed by Minority Executive Directors Coalition and Achievement Architects North, 2004Page 1

1234

Never / Sometimes / Often / Always
Questions
For each question, circle the number that applies to your rating. Please add any comments that will help us understand your rating. /

Rating

  1. When I visit this agency or meet with an agency staff person, I feel I am treated with respect.
Comments: / 1 2 3 4 N/A
  1. Individuals and families are encouraged to decide what services they need.
Comments: / 1 2 3 4 N/A
  1. When I talk to others similar to me (race, gender, age, physical abilities, etc.) they tell me they had a positive experience with this agency.
Comments: / 1 2 3 4 N/A
  1. I am made to feel welcome and comfortable when I interact with members of this agency?
Comments: / 1 2 3 4 N/A
  1. I see my culture / ethnicity reflected in the written materials and in the environment of this agency.
Comments: / 1 2 3 4 N/A
  1. I feel this agency’s programs meet my needs.
Comments: / 1 2 3 4 N/A
  1. Members of this agency understand and affirm my culture/ethnicity.
Comments: / 1 2 3 4 N/A
  1. I am able to easily read and understand written materials given to me by members of this agency.
Comments: / 1 2 3 4 N/A
  1. When I talk to members of this agency, I feel I am listened to and understood.
Comments: / 1 2 3 4 N/A
  1. When I interact with members of this agency, I see people who look like me.
Comments: / 1 2 3 4 N/A
  1. In what ways did this agency take steps to appreciate your culture, communications style, language, needs and expectations?
  1. What did this agency do to make you feel valued and respected?
  1. Any other comments or experiences you would like to share?

Developed by Minority Executive Directors Coalition and Achievement Architects North, 2004Page 1