Att C_NAMCS CLAS Questionnaire

Attachment C – Questionnaire

Form Approved OMB No. 0920-XXXX
Exp. Date: XX/XX/20XX

National Ambulatory Medical Care Survey Supplement on
Culturally and Linguistically Appropriate Services
Notice – Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid
OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office,
1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).

Assurance of confidentiality – All information which would permit identification of an individual, a practice, or
an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors,
and agents only when required and with necessary controls, and will not be disclosed or released to other
persons without the consent of the individual or establishment in accordance with section 308(d) of the Public
Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act
(PL107-347).

This survey is affiliated with the National Ambulatory Medical Care Survey (NAMCS). The survey should only be
completed by the physician to whom it is addressed. The purpose of this survey is to understand the provision
of culturally and linguistically appropriate services among office-based physicians. Culturally and linguistically
appropriate services consider cultural health beliefs, practices, and preferred languages associated
with various racial, ethnic, linguistic or religious groups. Your participation in this survey is voluntary
and greatly appreciated. Your answers are completely confidential. If you have questions or comments
about this survey, please call xxx-xxx-xxxx.
1. Including residency, how many years have you been providing direct care for patients in an
office-based setting? ____
2. What is your specialty?
General practice/family medicine
Internal medicine
Pediatrics
Obstetrics and gynecology
Geriatrics
Other (please specify): ___________________

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Attachment C – Questionnaire

3. Do you provide direct care for patients in an office-based setting?
Yes
No

Please stop here and return the questionnaire in the

I am no longer in practice

envelope provided. Thank you for your time.

4. What percent of your patient population is represented by each of the following categories?
Write “0” for any categories with no patients. Values should add to 100.
_____ Hispanic or Latino, of any race
_____ American Indian or Alaska Native, not Hispanic or Latino
_____ Asian, not Hispanic or Latino
_____ Black, not Hispanic or Latino
_____ Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
_____ White, not Hispanic or Latino
_____ Two or more races, not Hispanic or Latino
_____ I don’t know
5. Are you fluent in a language besides English?
Yes
No
6. How many languages, other than English, do you feel comfortable enough to provide
healthcare services?
0
1
2
3
4 or more
7. What is your sex?
Female
Male
8. Are you Hispanic, Latino/a, or Spanish Origin? (Check all that apply)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
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Yes, Another Hispanic, Latino/a or Spanish origin

Attachment C – Questionnaire

9.

What is your race? (Check all that apply)
White

Korean

Black or African American

Vietnamese

American Indian or Alaska Native

Other Asian

Asian Indian

Native Hawaiian

Chinese

Guamanian or Chamorro

Filipino

Samoan

Japanese

Other Pacific Islander

10. In what setting do you typically provide care to the most patients? (Check all that apply)
Solo or group practice
Freestanding clinic or urgent care center
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, county, 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 [If you select only hospital
emergency/outpatient department, go to item 42]
None of the above [If you select only None of the above or only hospital emergency/outpatient
department and None of the above, go to item 42]
For the remaining questions, please provide answers reflecting your experiences at the location where
you see the most patients that are not in hospital emergency or hospital outpatient departments. If
you feel you see the same number of patients at more than one location please select one.
11. What is the county, state, zip code for the location where you typically see the most patients?
Country USA County __________________ State__________________ Zip code __________
12. Did you receive any training in cultural competency in your clinical training programs including
medical school and residency? Training in cultural competency includes educational
opportunities that address topics of culture in settings such as employee orientation,
continuing medical education, conferences, or webinars.
Yes
No

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13. After medical school and residency, have you participated in training for cultural competency
such as continuing medical education (CME)?
Yes
No [SKIP to item 15]
a. Which of these population groups have been addressed in the training(s) for cultural
competency 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): ___________
b. Which of the following areas have been typically included in training(s) for cultural
competency in which you have participated? (Check all that apply)
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):___________
c. Was your participation in training for cultural competency to satisfy a continuing medical
education unit (CME) requirement or as requirement for credentialing?
Yes
No
14. Within the past 12 months, have you participated in any training for cultural competency?
Yes
No [SKIP to item 15]

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Attachment C – Questionnaire

a. Which of these population groups have been addressed in the training(s) for cultural
competency in which you have participated in the past 12 months? (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): ___________
b. Which of the following areas have been typically included in training(s) for cultural
competency in which you have participated in the past 12 months? (Check all that apply)
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):___________
c. Was your participation in training for cultural competency in the past 12 months to satisfy a
continuing medical education unit (CME) requirement or as requirement for credentialing?
Yes
No
15. Is training in cultural competency required for newly hired physicians who join your practice?
Yes
No
16. How often does your practice offer or make available training in cultural competency?
Annually
Biannually
Quarterly
Other (Please specify): ________________________
Not applicable: my practice does not offer or make available training in cultural competency.

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Attachment C – Questionnaire

17. Does your practice have at least one written policy related to the provision of culturally and
linguistically appropriate services?
Yes
No [SKIP to item 18]
I don’t know [SKIP to item 18]
a. If you work in a non-solo practice, how aware are you of your practice’s written policy
related to culturally and linguistically appropriate services?
Not applicable
Not at all
Barely
Fairly well
Very well
18. In what format are printed materials provided to your patients with limited English literacy?
(Check all that apply)

Documents created with plain language software or reviewed for literacy level
Universal symbols (A sign recognized by most people. Example: a square around a plus sign for
first aid.)
Infographics (A visual image such as a chart or diagram used to represent information or data)
Other (please specify):_________________________________
Not applicable: no printed materials are available to my patients with limited literacy.
19. Which of these free language-assistance services are available to patients 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.
20. Do you use interpreters when working with patients who have limited English proficiency?
Yes
No [SKIP to item 21]

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Attachment C – Questionnaire

a. When you use interpreters how often do you use each type?
Often

Sometimes

Rarely

Never

Staff/contractor trained as a
medical interpreter

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Bilingual staff

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Patient’s relative or friend

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21. 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
22. What information does your practice record on your patients’ culture and language
characteristics? (Check all that apply)
Race/Ethnicity
Nationality/Nativity
Patient’s primary language
Sexual orientation/gender identity
Religion
Income
Other (please specify):____________________________
Not applicable: we do not collect information related to culture and language.
Not at all
23. How knowledgeable are you of your patients’
health beliefs, customs, and values? . . . .

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Barely
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Fairly Well Very Well
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Attachment C – Questionnaire

24. When assessing your patients’ medical needs, how
often do you consider:
a. Race/ethnicity? . . . . . . . . . . . . . . . . .
b. Other cultural factors such as health beliefs,
customs, values? . . . . . . . . . . . . . . . . .
25. When diagnosing your patients, how often do you
consider:
a. Race/ethnicity? . . . . . . . . . . . . . . . .
b. Other cultural factors such as health beliefs,
customs, values? . . . . . . . . . . . . . . . . .
26. When treating your patients, how often do you
consider:
a. Race/ethnicity? . . . . . . . . . . . . . . . . .
b. Other cultural factors such as health beliefs,
customs, values? . . . . . . . . . . . . . . . . .
27. When conducting health education with your
patients, how often do you consider:
a. Race/ethnicity? . . . . . . . . . . . . . . . .
b. Other cultural factors such as health beliefs,
customs, values? . . . . . . . . . . . . . . . . .

Often

Sometimes

Rarely

Never

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28. How often does your practice assess your services to patients for their cultural and linguistic
appropriateness?
More than 4 times a year
About 2 to 4 times a year
About once a year
Less than once a year
My services are not assessed for their cultural and linguistic appropriateness.

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Attachment C – Questionnaire

Mark your agreement or disagreement with the following statements.
By providing culturally and linguistically appropriate
Strongly
Disagree
services to my patients I expect:
Disagree
29. Improved patient satisfaction with the services
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provided
30. Improved comprehension of treatment and lifestyle
recommendations

Agree

Strongly
Agree

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31. Better adherence to treatment and lifestyle
recommendations

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32. Improved patient trust

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33. Improved quality of patient care (e.g. diagnostics,
communication, treatment)

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34. Decreased likelihood of liability/malpractice claims

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How has each of the following factors affected you in providing culturally and linguistically
appropriate services to your patients?
Helped
Helped a
Did not
Not
Little
Help
Applicable
35. Formal written policy . . . . . . . . . . . . . . .
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36. Organizational resources . . . . . . . . . . . . .

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37. Training in cultural competency . . . . . . . . .

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38. Personal knowledge about the prevailing beliefs,
customs, norms, and values of the diverse groups
in your patient load . . . . . . .

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39. Other, (please specify):
_______________________________________

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Attachment C – Questionnaire

40. 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 [SKIP to item 42]
Heard of it but do not know much about it
Know something about it
Very familiar with it
a. 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): __________________________
41. Has your practice adopted the National CLAS Standards?
Yes
No
I don’t know
42. We may contact you in the future on this topic. What is a reliable E-mail address for you?
_______________________________@_________________________________

I verify that this questionnaire was completed by the physician to whom it was
addressed.
Thank you for your participation. Please return your survey in the envelope provided. If you have
misplaced the envelope, please send the survey to: XXX XXXX, Durham, NC XXXXX.

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