Attachment 1 – Questions to be evaluated OMB #0920-0222; Expiration Date: 06/30/2015
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Cultural and Linguistic Competency in Health Care Self-Administered Mail Survey for Office-Based Physicians
How many years have you been providing direct care for ambulatory care patients? __________
What is your specialty?
General practice/family medicine
Internal medicine
Pediatrics
Obstetrics and gynecology
Geriatrics
Other (Please specify): _____________________
Are you multilingual?
Yes
No
3a. If yes to 3, in how many languages other than English do you have the skills to provide healthcare services?
1
2
3
4 or more
What is your sex?
Male
Female
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
What is your race? (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
In what setting do you typically provide care to the most patients?
Private office—based solo or group practice
Freestanding clinic/urgicenter (not part of a hospital outpatient department)
Community health center (e.g. Federally Qualified Health Center (FQHC), federally-funded clinics or “look-alike” clinics)
Mental health center
Non-federal government clinic (e.g. state, country, city, maternal and child health, etc.)
Family planning clinic (including Planned Parenthood)
Health maintenance organization or other prepaid practice (e.g. Kaiser Permanente)
Faculty practice plan (an organized group of physicians that treat patients referred to an academic medical center
Hospital emergency or hospital outpatient department
None of the above
What is the street name for the location where you typically see the most patients?
Street ________________
For the remaining questions on this questionnaire, please provide answers reflecting your experiences at this location.
Did you receive cultural competency training in any of your clinical training programs (i.e. medical school and residency)?
Yes
No
After your clinical training, have you since participated in cultural competency training (e.g., continuing education)?
Yes
No
10a. If yes to 10, within the past 12 months, have you participated in any cultural competency training?
Yes
No
10b. If yes to 10, which of these population groups have been addressed in the cultural competency training(s) in which you have participated? (Check all that apply)
Racial/ethnic minorities
Religious groups
Lesbian, gay, bisexual, transsexual (LGBT) populations
Persons with limited English proficiency (LEP)
Inmates/ex-offenders
Other (please specify): ___________
10c. If yes to 10, which of the following topical areas have been typically included in cultural competency training(s) in which you have participated?
Cultural beliefs, values, and behaviors
Organizational policies, plans, and protocols regarding culturally and linguistically appropriate services
Health disparities
Complementary and alternative healing practices
Other (please specify):___________
10d. If yes to 10, was your participation in cultural competence training to satisfy a continuing education unit (CEU) requirement or as requirement for credentialing?
Yes
No
Is cultural competency training required as a condition of employment by your practice?
Yes
No
How often does your practice offer or make available in-service cultural competency training (either from an internal or external source)?
Annually
Biannually
Quarterly
Other (Please specify): ________________________
Not applicable: my practice does not offer in-service cultural competency training.
For the purposes of this survey, literacy is defined as the ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential
In what format are printed materials that are translated in language(s) other than English provided to your patients with limited literacy? (Check all that apply)
Documents created with plain language software or reviewed for literacy level
Universal symbols
Infographics
Other (please specify):________________
Not applicable: no printed materials are available to my patients with limited literacy.
Which methods are used to inform your patients of free language assistance services available in your practice? (Check all that apply)
Translated informational documents
Recorded messages in different languages on telephone lines
Translated signage and notices at key points of contact throughout the office
Other (please specify) __________
Not applicable: free language assistance is not available to my patients.
Which methods are used to inform your patients of free language assistance services available from external sources? (Check all that apply)
Translated informational documents
Recorded messages in different languages on telephone lines
Translated signage and notices at key points of contact throughout the office
Other (please specify) __________
Not applicable: free language assistance is not available to my patients.
Do you utilize interpreters to work with patients who are limited English proficient? (Limited English Proficient patients: patients who are unable to communicate effectively in English because their primary language is not English and they have not developed fluency in the English language.)
Yes
No
16a. If yes to 16, how often do you use professional interpreters?
Seldom
Sometimes
Often
What types of materials, in language(s) other than English, are available to your patients? (Check all that apply)
Wellness/Illness related education
Patient rights/ Informed consent documents
Advanced directives
Payment
Care plan
Other (Please specify):_________________
Not applicable: no translated materials are available to my patients
For the purposes of this survey, culture is defined as the integrated patterns of thoughts, communications, actions, customs, beliefs, values, and institutions associated with, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics.
What information does your practice collect on your patients’ culture and language characteristics? (Check all that apply)
Race/Ethnicity
Nationality/Nativity
Patient’s primary language
Sexual orientation/gender identity
History of criminal justice system involvement
Other (please specify):______________
Not applicable: we do not collect information related to culture and language.
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Not at all |
Seldom |
Sometimes |
Often
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When assessing your patients’ needs, how often do you consider: |
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When diagnosing your patients, how often do you consider: |
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When treating your patients, how often do you consider: |
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When conducting health education with your patients, how often do you consider: |
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Not at all |
Barely |
Fairly Well |
Very Well
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For the culturally and linguistically diverse groups in your patient load, how knowledgeable are you of their: |
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How often are your services to patients formally evaluated for their cultural and linguistic appropriateness?
Less than once a year
About once a year
About 2 to 4 times a year
More than 4 times a year
What outcome(s) do you expect by providing culturally and linguistically appropriate services to your patients? (CHECK ALL THAT APPLY)
Satisfaction with services
Comprehension of treatment and lifestyle recommendations
Health status/outcomes
Adherence to treatment and lifestyle recommendations
Improved patient trust
Improved quality of patient care (e.g. diagnostics, communication, treatment)
Decreased likelihood of liability/malpractice claims
Other(s) (Please specify): __________________________________________________
I do not expect any outcomes in providing culturally and linguistically appropriate services to my patients.
I do not provide culturally and linguistically appropriate services.
Does your practice have at least one policy in place related to the provision of culturally and linguistically appropriate services?
Yes
No
I don’t know
32a. If yes to 32, how aware are you of your practice’s culturally and linguistically appropriate services -related policy?
Not at all
Barely
Fairly well
Very well
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Helped |
No Effect |
Hindered |
Not Applicable |
How has each of the following factors affected you in providing culturally and linguistically appropriate services to your patients: |
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Are there additional factors that have helped you provide culturally and linguistically appropriate services to your patients?
Yes. Please list them. ______________________
No.
Are there additional factors that have hindered you in providing culturally and linguistically appropriate services to your patients?
Yes. Please list them. _____________________
No.
How familiar are you with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards)?
Never heard of it
Heard of it but do not know much about it
Know something about it
Very familiar with it
39a. How have you gained knowledge about the National CLAS Standards? (CHECK ALL THAT APPLY)
Through initial employment orientation in my current organization
Through other trainings such as in-service, continuing education, or professional development activities in my current organization
Through attending a training/meeting/webinar outside of my current organization
Through reading a report, publication, newsletter, or other materials publicly available – (Please list the title of the material you read) __________________________________
Other (Please specify):___________________________________________
Has your practice adopted the National CLAS Standards?
Yes
No
I don’t know
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lacreisha Ejike-King |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |