A.

BIOGRAPHICAL CHARACTERISTICS

1. Name :
_______________________________________________________________
2. Birthday/Age :
______________________________________________________/________
3. Specialization :
_______________________________________________________________
4. Eligibility :
_______________________________________________________________
5. Gender : ( ) Male ( ) Female
6. Civil Status : ( ) Single ( ) Separated ( ) Widow/ Widower
( ) Married ( ) Single Parent
7. Seminars and Trainings Attended Related to Cultural Competence:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

B. EMPLOYMENT DATA
B.1. Present Employment Status
_____ Regular or Permanent
_____ Temporary
_____ Casual
_____ Contractual
_____ Self-employed

B.2. Present Occupation. Please indicate your present occupation.

________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

B.3. What are your reasons for staying on the job? You may check more than one answer.
______ Salaries and benefits
______ Career challenge
______ Related to special skills
______ Related to course of program of study
______ Proximity to residence
______ Peer influence
______ Family influence
______ other, please specify
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

B.4. How long did you stay in your first job?

______ 1 to 6 months
______ 7 to 11 months
______ 1 year to less tan 2 years
______ 2 years to less than 3 years
______ 3 years to less than 4 years
______ other, please specify
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

B.5. How did you find your job?

______ Response to an advertisement
______ As walk-in applicant
______ Recommended by someone
______ Information from friends
______ Arranged by school’s job placement officer
______ Family business
______ Job fair or Public Employment Service Office (PESO)
______ other, please specify
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

B.6. What is your initial gross monthly earning in your first job after college?
______ Below 1,500.00 SAR
______ 1,500.00 SAR to less than 2,000.00 SAR
______ 2,000.00 SAR to less than 2,500.00 SAR
 ______ 2,500.00 SAR to less than 3,000.00 SAR
______ 3,000.00 SAR to less than 3,500.00 SAR
______ 3,500.00 SAR and above

C. CULTURAL COMPETENCY INVENTORY for CLASSROOM TEACHERS

Directions : Please assess your agreement to the following items using the scale:

5 – Always 3 – Sometimes 1 - Never

4 – Frequent 2 - Seldom

PHYSICAL ENVIRONMENT, MATERIALS & RESOURCES

1. I display pictures, posters and other materials that reflect the cultures and ethnic backgrounds
of children and families served by my program or school.
2. I insure that magazines, brochures, and other printed materials in reception areas are of
interest to and reflect the different cultures of children and families served by my program or
school.
3. When using videos, films or other media resources for health education, treatment or other
interventions, I insure that they reflect the cultures of children and families served by my
program or school.
4. When using assessment, I insure that that these are unique to the cultural and ethnic
backgrounds of children and families served by my program or school.
5. I insure that toys and other play accessories in reception areas and those, which are used
during assessment, are representative of the various cultural and ethnic groups within the
local community and the society in general.

COMMUNICATION STYLES

6. For children who speak languages or dialects other than English, I attempt to learn and use
key words in their language so that I am better able to communicate with them during
assessment, treatment or other interventions.
7. I attempt to determine any familial colloquialisms used by children and families that may
impact on instruction.
8. I use visual aids, gestures, and physical prompts in my interactions with children who have
limited English proficiency.
9. I use bilingual staff or trained/certified interpreters for instruction and assessment with
children who have limited English Proficiency.

10. I use bilingual staff or trained/certified interpreters during assessments, sessions, meetings,
and for or other events for families who would require this level of assistance.

11. When interacting with parents who have limited English proficiency I always keep in mind
that:
_____ * limitations in English proficiency are in no way a reflection of their level of
intellectual functioning.
_____ * their limited ability to speak the language of the dominant culture has no bearing
on their ability to communicate effectively in their language of origin.
_____ * they may or may not be literate in their language of origin or English.

12. When possible, I insure that all notices and communiqués to parents are written in their
language of origin.

13. I understand that it may be necessary to use alternatives to written communications for some
families, as word of mouth may be a preferred method of receiving information.
 14. I understand the principles and practices of linguistic competency and:
_____ * apply them within my program or agency.
_____ * advocate for them within my program or agency.

15. I understand the implications of literacy within the context of my roles and responsibilities as
teacher of different cultures.

16. I use alternative formats and varied approaches to communicate and share information with
children and/or their family members who experience difficulty.

VALUES AND ATTITUDES

17. I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other
than my own.
18. In group discussions, I discourage children from using racial and ethnic slurs by helping them understand
that certain words can hurt others.
19. I screen books, movies, and other media resources for negative cultural, ethnic, or racial stereotypes before
sharing them with children and their parents served by my program or school.
20. I intervene in an appropriate manner when I observe other staff or parents within my program or school
engaging in behaviors that show cultural insensitivity, bias or prejudice.
21. I understand and accept that family is defined differently by different
cultures (e.g. extended family members, fictive kin, godparents).
22. I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of
acculturation into the dominant culture.
23. I accept and respect that male-female roles in families may vary significantly among different cultures (e.g.
who makes major decisions for the family, play and social interactions expected of male and female
children).
24. I understand that age and life cycle factors must be considered in interactions with individuals and families
(e.g. high value placed on the decisions of elders or the role of the eldest male in families).
25. Even though my professional or moral viewpoints may differ, I accept the family/parents as the ultimate
decision makers for services and supports for their children.
26. I recognize that the meaning or value of education may vary greatly among cultures.
27. I recognize and understand that beliefs and concepts of emotional well-being vary significantly from culture
to culture.
28. I understand that beliefs about mental illness and emotional disability are culturally-based. I accept that
responses to these conditions and related instruction are heavily influenced by culture.
29. I accept that religion and other beliefs may influence how families respond to educational situations and
cases.
30. I recognize and accept that folk and religious beliefs may influence a family's reaction to school practices.
31. I understand that traditional approaches to disciplining children are influenced by culture.
32. I understand that families from different cultures will have different expectations of their children for
acquiring toileting, dressing, feeding, and other self-help skills.
33. I accept and respect that customs and beliefs about schooling, and its value, are different from culture to
culture.
34. Before visiting or providing services in the home setting, I seek information on acceptable behaviors,
courtesies, customs and expectations that are unique to families of specific cultures and ethnic groups
served by my program or school.
35. I seek information from family members or other key community informants that will assist in service
adaptation to respond to the needs and preferences of culturally and ethnically diverse children and families
served by my program or school.
36. I advocate for the review of my program's or school's mission statement, goals, policies, and procedures to
insure that they incorporate principles and practices that promote cultural diversity and cultural
competence.
 D. CHECKLIST ON EDUCATIONAL GOALS

Please check ( √ ) in the first column the statements of educational goals which agree with your desires and expectations
regarding your child’s Education. Put another check ( √ ) on the right column to measure the extent of its desirability
based on your perception.

Scaling:
5 - Highly desirable
4 - Desirable
3 - Occasionally desirable
2 - Not desirable/ applicable
1 - Indifferent

Put a Level of Desirability

check Educational Goals and Aspirations
(√ ) 5 4 3 2 1

( )
1. Understand basic moral and spiritual values
( )
2. Acquire a set of values and an ethical system by which to live
( )
3. Develop correct values
( )
4. Desire and achieve socially responsible behavior
( )
5. Develop intellectual prowess
( )
6. Develop critical thinking
( )
7. Acquire proficiency in expressing one’s self
( )
8. Develop effective study skills
( )
9. Develop a command of basic mathematical processes
( )
10. Provide opportunities for worthwhile co-curricular activities
( ) 11. Provide opportunities for the appreciation of arts, music and other
aesthetics experiences
( )
12. Discover and develop creative talent
( )
13. Understand the scientific method and how it works
( )
14. Understand scientific and technological progress
( )
15. Acquire self-reliance
( )
16. Develop the ability to work cooperatively
( )
17. Train in effective leadership
( )
18. Train in intelligent followership
( )
19. Provide opportunities to meet people
( ) 20. Acquire refined manners to be able to conduct one’s self properly in
any kind of gathering
( )
21. Provide guidance in the balanced development of one’s personality
( ) 22. Provide opportunities for self-discovery, self-expression and
creativity
( )
23. Develop the ability to deal constructively with psychological tension
( )
24. Learn how to make use of leisure time
( )
25. Acquire a wide range of interests
( ) 26. Develop the ability to adapt to changing conditions and to learn
from mistakes
( )
27. Maintain good physical and mental health
( )
28. Provide adequate sex education
( )
29. Select and prepare for an occupation or vocation
( )
30. Prepare for marriage and family life
( ) 31. Develop an understanding of the concept of and need for
responsible parenthood
( ) 32. Understand the abilities and skills needed for a successful and
worthwhile family membership
( )
33. Develop an understanding of the meaning of life
( )
34. Learn how to deal with life, its problems and stress
( )
35. Develop the ability to plan one’s life
( ) 36. Develop intellectual skills and concepts necessary for civic
competence
( ) 37. Develop a basic understanding of the operation of one’s government
according to the constitution
( )
38. Develop a basic understanding of the essentials of good citizenship
( )
39. Develop an understanding of the economic goals of the country
( )
40. Train in intelligent action as consumers
( ) 41. Know the contemporary conditions of one’s community and the
nation as a whole and one’s role in the community or in the nation
( )
42. Learn and appreciate cultural heritage
( )
43. Train for community leadership
( ) 44. Provide opportunities for active participation in projects for
community up liftment
( )
45. Train in the intelligent use of natural resources

46. Others (Note : Please use the space below for other goals that you
( ) expect from a basic education.)

Thank you!