* 1. Please List Your County within Pennsylvania

* 2. Please select your affiliation (check all that apply):

* 3. Does your county have culturally appropriate services to support diverse youth and families from the following communities? 

  Not At All Barely Fairly Well Very Well Unsure
Black or African American
Asian or Pacific Islander
American Indian or Alaska Native
Lesbian, Gay, Bi, Transgender, and Questioning (LGBTQ)

* 4. How well does your county understand how the causes of mental health/illness are viewed by diverse groups in your area? 

  Not At All Barely Fairly Well Very Well Unsure
Black or African American
Asian or Pacific Islander
American Indian or Alaska Native
Lesbian, Gay, Bi, Transgender, and Questioning (LGBTQ)

* 5. Does your county have the following CLC supports? (check all that apply)

* 6. As a matter of formal policy, does your county. . .

  No Policy Considering Policy Currently Writing Formal Policy Policy In Place Unsure
use culture specific treatment approaches?
envision community empowerment as a treatment goal?
provide or facilitate childcare for youth and families?
provide or facilitate transportation for youth and families (e.g., bus tickets, ride-sharing)?
allow access after regular business hours for youth and families (e.g., agreements with crisis-providers,
specifically consider culture in service plans?

* 7. Is your County able to describe the languages and dialects used by diverse groups in your service area?

* 8. Does your County have a mission statement that incorporates cultural and linguistic competence?

* 9. Does your County identify opportunities within culturally diverse communities for you to:

  Not At All Sometimes Fairly Often Very Often Unsure Not Available in my County
Attend cultural or ceremonial functions?
Purchase goods or services from a variety of diverse merchants (either for personal use or job-related duties)?
Support immigrant populations?
Support refugee populations?
Participate in recreational or leisure time activities important to diverse communities?
Participate in career awareness days to support a diverse workforce?
Participate in community education activities?

* 10. Does your county have linkages with institutions of higher education (e.g., colleges, universities, or
professional schools) that could provide you with accurate information concerning communities of
color and CLC?

* 11. Is there policy for the provision of interpretation services for youth and families with Limited English Proficiency and those who are deaf or have hearing impairments?

* 12. Does your County:

  Never Seldom Sometimes Regularly Unsure
Translate and use consent forms, educational materials and other information in other languages?
Insure materials address the literacy needs of the person served?
Assess the health literacy of person served?
Employ specific interventions based on the health literacy levels of persons served?

* 13. Does your County have the following available in languages other than English? (Check all that apply)

* 14. Does your County reach out to and engage the following individuals, groups, or entities in health and mental health promotion and disease prevention initiatives:

  Never Seldom Sometimes Regularly Unsure
Places of worship and spiritual leaders?
Traditional healers, medicine people, naturopath, herbalists, etc.? Providers of complimentary and alternative medicine?
Mental health providers, dentists, chiropractors, or licensed midwives?
Ethnic publishers, radio, cable or television stations or personalities, or other ethnic media sources?
Tribal, cultural, or advocacy organizations?
Local business owners (e.g., barbers, sports clubs, restaurateurs, casinos, and other ethnic businesses)?
Social organizations (e.g., civic/neighborhood associations, sororities, fraternities, ethnic associations)?

* 15. Does your county conduct an open house or similar event to which providers, consumers, and others concerned with service delivery to communities of color are invited?

* 16. Does your county utilize cultural consultants who can help them work more effectively within a cultural context?

* 17. Please list any additional policies supporting cultural and linguistic competence not identified by this instrument.