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New Jersey Statewide Network For
Cultural Competence Survey

This survey form may be completed by a non-profit organization representative

*Required Fields
 
*Name of Non-Profit Organization:
*Brief Description of Services (300 characters max):
*Contact Person:
*Mailing Address:
Street:
 
City:    County:
State: Zip:
*Phone Number: - - Ext:
Fax Number: - -
E-mail Address:
Web Site Adress:
 
   *County Served:(Please check all the counties your organization serves.)
  Atlantic
Bergen
Burlington
Camden
Cape May
Cumberland
Essex
Gloucester
Hudson
Hunterdon
Mercer
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
 
  *Language Spoken:(Please check all the languages spoken by your staff.)
  All
American Sign Language
Arabic
Armenian
Bangaladesh
Bengali
Cambodian
Cantonese
Chamorro
Chinese
Communication Devise
Creole
Croatian
Czech
Danish
Dutch
English
Farsi
French
German
Greek
Gujarat
Hebrew
Hiligaynon
Hindi
Hmong
Hungarian
Ilocano
Ilonggo
Indian
Indian Dialect
Iranian
Italian
Japanese
Kenya
Korean
Lithuanian
Loatian
Mandann
Mandarin
Nigerian
Pakistani
Perian
Polish
Portuguese
Romanian
Russian
Samoan
Serbian
Slovak
Spanish
Srilanka
Swahili
Swedish
Tagalog
Telugu
Thai
Tigrina
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
West African
Yiddish


  To enter more languages that you don't find in the list above (separate them with a comma, ex language1,language2):
 
 
*Group Served:(Please check all the groups served by your staff.)
African American
All
Arabic
Asian
Caucasian/White
Chinese
Dutch
English
European
Filipino
German
Haitian
Hispanic
Indian
Jewish
Korean
Mexican
Native American
Pacific Islander
Polish
Portuguese
Russian
Vietnamese
  To enter more groups that you can't find in the list above (separate them with a comma, ex group1,group2):
 
 
       
 

 


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