Survey for Multicultural Individuals

Father's Culture

Culture Name

e.g. Jewish, Italian, Chinese, African American, mixed European

Race

What race does this culture belong to?

Circle one:

White

Asian

Black

Hispanic

Native

Other

How connected is your parent to this culture?

1 for not connected at all. 5 for very connected.

Circle one:

1

2

3

4

5

In what ways is your parent connected to this culture?

e.g. food, language, holidays, religion, etc.

How connected are you to this culture?

1

2

3

4

5

In what ways are you connected to this culture?

In what ways are you more or less connected to this culture than your father?

Mother's Culture

Culture Name

Race

White

Asian

Black

Hispanic

Native

Other

How connected is your parent to this culture?

1

2

3

4

5

In what ways is your parent connected to this culture?

How connected are you to this culture?

1

2

3

4

5

In what ways are you connected to this culture?

In what ways are you more or less connected to this culture than your mother?