360° Cultural Health Assessment Survey
An initial evaluation of your cultural health and intelligence.
Privacy
All information you submit is private and confidential. Data will be utilized to help determine professional development needs.
Personal Information
All fields required.
Your Name
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First Name
Last Name
School Name
*
City and State of School
*
Your Title
*
E-mail
*
Best Phone Number to Reach You
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-
Area Code
Phone Number
Age Range
20 to 30
31 to 40
41 to 50
51 to 60
60+
Prefer not to say.
Gender
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Male
Female
Prefer Not to Say
How do you identify?
*
African-American
Black (not American)
Asian
Caucasian
European
Hispanic / Latino
Indian (from India)
Native American
Pacific Islander
Other
Culture and Education Questions
1. Do you have a desire to learn to more effectively connect with people of diverse cultures?
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Yes, very much.
No, I don't see a need.
Maybe, but I'm not sure.
2. How often do you work with students and families of diverse cultures?
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Not at all.
Infrequently.
Sometimes.
Frequently.
2. Do you presently work with other teachers, administrators, or support staff of diverse backgrounds?
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Not at all.
Infrequently.
Sometimes.
Frequently.
4. Think of your core group of friends. How much cultural and ethnic diversity is there amongst them?
None of my friends are from diverse backgrounds.
Just a few of my friends are from diverse backgrounds.
Several of my friends are from diverse backgrounds.
Most of my friends are of diverse backgrounds.
All of my friends are from diverse backgrounds.
5. How many languages do you presently speak well?
Please type or choose the number that best represents your answer.
6. On a scale of 0 to 10, 10 being very skilled and 0 being not skilled at all, what do you believe is your present level of cultural skill?
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Please type or choose the number that best represents your answer.
7. On a scale of 0 to 10, 10 being highly skilled, how well would you like to master the skill of working with people of diverse cultures?
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Please type or choose the number that best represents your answer.
8. How do you believe that learning more about working with diverse cultures would benefit you and your school?
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9. What are your personal and professional goals as it regards working with people of diverse cultures?
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10. Would you be open to taking a detailed 30 minute cultural mastery assessment that measures your current cultural skill level?
Yes, I would like to get this feedback.
No, I am not interested in taking a deeper cultural assessment.
Additional Information
Please share with us anything else that might be helpful to understand cultural needs or strengths in your school environment.
*
Submit the Survey.
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