Cultural Diversity and Sensitivity Self-Evaluation Form
Using a scale of 1 to 5, with 1 = never and 5 = always, please answer the following questions:
| Question | Response Value |
|---|---|
| 1. I am comfortable with my culture and can compromise on situations without sacrificing my integrity. | |
| 2. I think about what I say and how it may affect people with different beliefs and practices. | |
| 3. I am aware that others may stereotype me, and I am willing to proactively get involved and share my beliefs and practices. | |
| 4. I evaluate what the real reasons are when I encounter a conflict with the aged, the disabled, or persons of a different culture. | |
| 5. I am aware of sensitive issues when I am around women and persons of different beliefs and races. | |
| 6. I ask for clarification when I do not understand what others mean. | |
| 7. I am aware of my assumptions about others who are culturally or racially different than myself and I am okay with it. | |
| 8. I object when others tell ethnic jokes. | |
| 9. I listen without interrupting when someone is speaking. | |
| 10. I am comfortable forming friendships with people of different cultures. | |
| 11. I find ways to learn more about different cultures and how to communicate effectively. | |
| 12. I realize that flexibility and empathy allow me to evaluate persons of different cultures without imposing any judgments, which allows me to collaborate effectively. | |
| 13. I recognize that there are ways other than mine. | |
| 14. I accept people for who they are regardless of color, educational achievement, financial status, age, physical limitations, or gender. | |
| 15. I don’t mind apologizing if I have wronged or offended someone. | |
| 16. I respect that others may have a different interpretation of personal space. | |
| 17. I treat people differently than the biases and prejudices of members of my culture. | |
| 18. I do not look down on people who do not speak English fluently or may have an accent. | |
| 19. I understand that there are many ways to communicate. | |
| 20. I use simple and common phrases when around the elderly, those with physical limitations, or someone of a different culture who may not speak my language proficiently. | |
| Add up all of the numbers for a total score. |
Total score: Outstanding: 95 to 100
Good: 85 to 94
Average: 75 to 84
Needs improvement: 74 or less
(This tool is intended for personal use only. It is designed to be performed as a personal self-assessment. No reliable test that measures stability, equivalence, and homogeneity has been done.)