RISE/RDBO Provider Survey
For potential referrals
First and Last Name *
Your answer
Clinic Affiliation and Location *
Your answer
Please provide a way for us to contact you. *
Your answer
Are you interested in having more patients from diverse cultural backgrounds? *
Do you accept OHP? *
What do you estimate is your current percentage of patients from diverse cultural backgrounds? *
Your answer
Do you ask your patients' preferences for interpreters? (eg., gender, use of family member) *
Do you familiarize yourself with your patients' cultural backgrounds? *
Have you taken a class on cultural sensitivity in the last 3 years? *
If yes, are you interested in taking additional classes in cultural sensitivity?
If no, are you now interested in a class or presentation on cultural sensitivity?
Could you briefly share what you have found to be effective strategies when treating patients from other cultures?
Your answer
Please share any other information you think is important for us to know about you.
Your answer
Do you know other providers that would like to take this survey?
Your answer
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This form was created inside of Refugee & Immigrant Services and Empowerment.