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?