TCH Course/Unit Evaluation Form

Appendix C
Think Cultural Health (TCH) Course/unit Evaluation Questions

Form Approved
OMB No. 0990-0407
Exp. Date XX/XX/20XX

Course 1
A little about you
1. Self-rating
Please rate your agreement with the below statements based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can define culture.
b. I can describe the three parts of the case for CLAS.
c. I can identify the barriers to access of care that may be attributed to a lack of cultural
competency.
d. I can differentiate and balance fact-centered and attitude/skill-centered approaches to
developing cultural competency.
e. I understand frameworks for developing cultural competency.
f. I can define patient-centered care.
g. I can explain the importance of distinguishing between illness and disease.
h. I can apply models of effective provider-patient communication.
i. My colleagues/staff are supportive of me completing this course.
2. Program Rating.
Please rate your agreement with the below statements based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. The information in this course was presented in an easily understood manner.
b. The case studies enhanced the content presented in this course.
c. The language (e.g., in the instructions, in the content, etc.) was easy to understand.
d. The technology features (e.g., embedded videos, Flash, etc.) enhanced the content
presented in this course.
e. The content in this course was presented in an engaging manner.
f. The information presented in this course is relevant to my daily work.
g. Overall, the course is an effective tool to increase my knowledge of cultural and linguistic
competency.
3. Based on your previous knowledge and experience, the content in this course was:
a. Too elementary
b. Appropriate
c. Too advanced
4. As a result of completing this course, please rate your agreement with the below statements
based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can define culture.
b. I can describe the three parts of the case for CLAS.
c. I can identify the barriers to access of care that may be attributed to a lack of cultural
competency.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0990-0407. The time required to complete this information collection is estimated to
average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer

Appendix C Form Approval
Think Cultural Health (TCH) Course/unit Evaluation Questions
d. I can differentiate and balance fact-centered and attitude/skill-centered approaches to
developing cultural competency.
e. I understand frameworks for developing cultural competency.
f. I can define patient-centered care.
g. I can explain the importance of distinguishing between illness and disease.
h. I can apply models of effective provider-patient communication.
i. I am excited to use the information I learned in this course in my daily work.
j. I will incorporate the information I learned in this course into my daily work.
5. Would you recommend this course to a colleague?
a. Yes
b. No
i. If no, why?
6. Do you intend to complete the next Course in this e-learning program?
a. Yes
b. No
i. If no, why?
7. How do you think this Course could be better? (Enter text)
8. Do you feel that this course was free from commercial bias?
a. Yes
b. No
i. If no, why?
9. Was the disclosure of any financial or commercial interest made available to you?
a. Yes
b. No
10. May we contact you in the future to conduct a brief follow up survey?
a. Yes
i. If yes, please tell us how you would prefer to be contacted:
Email (please provide)
Telephone (please provide)
Mail (please provide)
b. No

Course 2
A little about you
1. Self-Rating
Please rate your agreement with the below statements based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can describe the importance of the role of language in patient-provider communications.
b. I can identify the legal and policy requirements for providing communication and language
assistance services.

Appendix C Form Approval
Think Cultural Health (TCH) Course/unit Evaluation Questions
c. I can describe the business practice issues related to providing communication and language
assistance services and indicate the costs of not doing so.
d. I can describe the components of effective interpersonal communication for individuals with
limited English proficiency.
e. I can describe the roles of an interpreter.
f. I can identify effective language access services related to written materials.
g. I can list characteristics of qualified interpreters and translators.
h. I can describe the components of the triadic interview process and roles to participants.
i. I can list the factors necessary for providers to work effectively with interpreters.
j. My colleagues/staff are supportive of me completing this course.
2. Program Rating.
Please rate your agreement with the below statements based on the following scale:
1 = Strongly Agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. The information in this course was presented in an easily understood manner.
b. The case studies enhanced the content presented in this course.
c. The language (e.g., in the instructions, in the content, etc.) was easy to understand.
d. The technology features (e.g., embedded videos, Flash, etc.) enhanced the content
presented in this course.
e. The content in this course was presented in an engaging manner.
f. The information presented in this course is relevant to my daily work.
g. Overall, the course is an effective tool to increase my knowledge of cultural and linguistic
competency.
3. Based on your previous knowledge and experience, the content in this course was:
a. Too elementary
b. Appropriate
c. Too advanced
4. As a result of completing this course, please rate your agreement with the below statements
based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can describe the importance of the role of language in patient-provider communications.
b. I can identify the legal and policy requirements for providing communication and language
assistance services.
c. I can describe the business practice issues related to providing communication and language
assistance services and indicate the costs of not doing so.
d. I can describe the components of effective interpersonal communication for individuals with
limited English proficiency.
e. I can describe the roles of an interpreter.
f. I can identify effective language access services related to written materials.
g. I can list characteristics of qualified interpreters and translators.
h. I can describe the components of the triadic interview process and roles to participants.
i. I can list the factors necessary for providers to work effectively with interpreters.
j. I am excited to use the information I learned in this course in my daily work.
k. I will incorporate the information I learned in this course into my daily work
5. Would you recommend this course to a colleague?

Appendix C Form Approval
Think Cultural Health (TCH) Course/unit Evaluation Questions
a. Yes
b. No
i. If no, why?
6. Do you intend to complete the next Course in this e-learning program?
a. Yes
b. No
i. If no, why?
7. How do you think this Course could be better? (Enter text)
8. Do you feel that this course was free from commercial bias?
a. Yes
b. No
i. If no, why?
9. Was the disclosure of any financial or commercial interest made available to you?
a. Yes
b. No
10. May we contact you in the future to conduct a brief follow up survey?
a. Yes
i. If yes, please tell us how you would prefer to be contacted:
Email (please provide)
Telephone (please provide)
Mail (please provide)
b. No

Course 3
A little about you
1. Self-Rating.
Please rate your agreement with the below statements based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can describe at least two aspects of the office environment that support cultural
competency.
b. I can assess my organization, office, or clinic, including resources, interactions, materials,
environment, and organizational strategies.
c. I can describe strategic planning processes that support cultural competency development.
d. I can describe the importance of data collection and analysis in the provision of culturally
competent care.
e. I can identify resources to collect, use and manage data to create community and practice
profiles and needs assessment.
f. I can describe the challenges to data collection and way to mitigate them.
g. I can describe the importance of developing health-related partnerships with the
community.
h. I can identify at least two components of forming community health partnerships and list at
least three characteristics of successful community partnerships.

Appendix C Form Approval
Think Cultural Health (TCH) Course/unit Evaluation Questions
i.
j.

I can describe the benefits of including minority community members in health
partnerships.
My colleagues/staff are supportive of me completing this course.

2. Program Rating.
Please rate your agreement with the below statements based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. The information in this course was presented in an easily understood manner.
b. The case studies enhanced the content presented in this course.
c. The language (e.g., in the instructions, in the content, etc.) was easy to understand.
d. The technology features (e.g., embedded videos, Flash, etc.) enhanced the content
presented in this course.
e. The content in this course was presented in an engaging manner.
f. The information presented in this course is relevant to my daily work.
g. Overall, the course is an effective tool to increase my knowledge of cultural and linguistic
competency.
3. Based on your previous knowledge and experience, the content in this course was:
a. Too elementary
b. Appropriate
c. Too advanced
4. As a result of completing this course, please rate your agreement with the below statements
based on the following scale:
1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree
a. I can describe at least two aspects of the office environment that support cultural
competency.
b. I can assess my organization, office, or clinic, including resources, interactions, materials,
environment, and organizational strategies.
c. I can describe strategic planning processes that support cultural competency development.
d. I can describe the importance of data collection and analysis in the provision of culturally
competent care.
e. I can identify resources to collect, use and manage data to create community and practice
profiles and needs assessment.
f. I can describe the challenges to data collection and way to mitigate them.
g. I can describe the importance of developing health-related partnerships with the
community.
h. I can identify at least two components of forming community health partnerships and list at
least three characteristics of successful community partnerships.
i. I can describe the benefits of including minority community members in health
partnerships.
j. I am excited to use the information I learned in this course in my daily work.
k. I will incorporate the information I learned in this course into my daily work.
5. Would you recommend this course to a colleague?
a. Yes
b. No
i. If no, why?

Appendix C Form Approval
Think Cultural Health (TCH) Course/unit Evaluation Questions
6. How do you think this Course could be better? (Enter text)
7. Do you feel that this course was free from commercial bias?
a. Yes
b. No
i. If not, why?
8. Was the disclosure of any financial or commercial interest made available to you?
a. Yes
b. No
9.

May we contact you in the future to conduct a brief follow up survey?
a. Yes
i. If yes, please tell us how you would prefer to be contacted:
Email (please provide)
Telephone (please provide)
Mail (please provide)
b. No