Very well

Cultural Competence Self-Assessment Tool
This questionnaire is intended to help identify your cultural competence training needs. Cultural
competence refers to the ability to work in ways that recognize and respect culturally based patterns of
behavior and the cultural strengths associated with people and ethnic communication different than your
own. The questionnaire is intended to help assess your strengths and weaknesses in addressing the
cultural diversity of your patients and colleagues. Feel free to copy this survey to use with your clinic staff
members. Circle the responses that most accurately reflect your perception.

Not at
all

Barely Fairly
well

Very
well

1. Do you know:

The prevailing beliefs, custom norms or
values of ethnic communities you serve?

1 2 3 4

How health/illness is defined by members

of the different ethnic communities in
your area?

1

2

3

4

What languages are used by the ethnic

communities in your area?

1

2

3

4

2. How well are you able to describe the strengths
of a given ethnic community?

1

2

3

4

3. Do you attend cultural, ritual, or ceremonial
functions sponsored or presented by ethnic
groups?

1

2

3

4

4. Do you have access to professionals or others
who can give you insight and respect to
understanding or reaching out to members of
ethnic communities?

1

2

3

4

5. Does the waiting room in your office or any of the exam rooms have magazines, books, art work
or cultural artifacts reflecting the ethnic communities that your serve?

None A few Some Many
1 2 3 4

UCare Provider Manual Revised January 2010

6. To what extent do you know the following risk factors of the ethnic communities in your service
area?

Not at

all
Barely Fairly

well
Very well

Infant mortality rates 1 2 3 4
Life expectancy rates 1 2 3 4
Disease prevalence 1 2 3 4
Educational attainment 1 2 3 4
Geographic location 1 2 3 4
Income differentials 1 2 3 4
Unemployment rates 1 2 3 4

7. To what extent do you know the following characteristics of your patients of diverse cultures?

Not at all Barely Fairly well Very well

Social History (how they came to
reside in your area)

1 2 3 4

Role of family/elders in decision
making

1 2 3 4

Availability and accessibility to
social service agencies

1 2 3 4

Basic health expectations 1 2 3 4

Add up your total score and then check the following scale to determine your level of cultural
competence.

55-72 Culturally competent
37-54 Knowledgeable of diversity
19-36 Minimal cultural awareness
18 or below Culturally unaware

Developed by The Center for Cross-Cultural Health, Through the Eyes of Others: Intercultural Resource Directory for Health
Care Professionals –Adapted with permission from James Mason.

UCare Provider Manual Revised January 2010

Preamble