Developing a Self-Assessment Toolfor Culturally - Office of Minority ...

Appendix D[INSERT NAME OF STUDY OR DATA COLLECTION EFFORT]STAFFING QUESTIONNAIREThank you for taking the time to complete this questionnaire. The purpose of this request is tocollect information on health care policies and practices that provide medical support orservices to meet the needs of clients of diverse linguistic, national, or cultural backgrounds.Participation in this study does not require that your agency have any sort of policies in placethat address the particular needs of certain cultural groups. There are no expectations orjudgments about services that are, or are not, offered by your agency. In the event that certainagencies report unique policies or practices that exceed current standards of care for diversegroups, prior permission will be requested from the participating agency to highlight in futurepublications information provided from those responses only. Anonymity is assured; data willbe reported as summaries without individual agency identification. A unique benefit of yourparticipation in this study is that your agency will receive a copy of actual responses submittedby your staff that may be useful to your health agency in identifying and monitoring CLASprovision for quality improvement and other reporting purposes.Although the focus of this questionnaire is on health care services provided to members ofdiverse cultural groups, the form is divided into four sections that cover specific topics withinthe broader inquiry. Depending on the structure of your agency, it may be appropriate fordifferent individuals in your agency to complete certain sections of the questionnaire based ontheir roles, responsibilities, and knowledge—thereby greatly reducing individual time and effort.You are encouraged to distribute certain sections or questions to the appropriate colleague inyour agency in order to complete as many questions as you can. Some questions call for yourbest single answer. Questions that call for multiple responses are labeled “Mark All ThatApply.”RETURN INSTRUCTIONSThank you again for your participation. There are two options for returning your completed questionnaire:1. Mail the completed form using the enclosed pre-paid envelope.If you have misplaced the envelope, please send the completed form to:Complete as appropriate2. Submit your completed form by facsimile transmission to:Complete as appropriatePaperwork Reduction Act StatementA federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless itdisplays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to vary from20-30 minutes with an average of .5 minutes per response, including time for reviewing instructions, searching existing datasources, gathering and maintaining the necessary data, and completing and reviewing the collection of information.COSMOS Corporation, December 2003