Heritage

Note: The greater the number of positive responses, the greater the
person’s identification with a traditional heritage. The one exception
to positive answers is the question about family name change. This
question may be answered negatively.
1. Where was your mother born?____________________________
2. Where was your father born? ______________________________
3. Where were your grandparents born?
(1) Your mother’s mother?______________________________
(2) Your mother’s father? ______________________________
(3) Your father’s mother? ______________________________
(4) Your father’s father? ________________________________
4. How many brothers _____ and sisters _____ do you have?
5. What setting did you grow up in? Urban _____ Rural _____
Suburban _____
6. What country did your parents grow up in?
Father _____
Mother _____
7. How old were you when you came to the United States? _____
8. How old were your parents when they came to the United
States? Mother _____ Father _____
9. When you were growing up, who lived with you? _____
10. Have you maintained contact with
a. Aunts, uncles, cousins? (1) Yes _____ (2) No _____
b. Brothers and sisters? (1) Yes _____ (2) No _____
c. Parents? (1) Yes _____ (2) No _____
d. Your own children? (1) Yes _____ (2) No _____
11. Did most of your aunts, uncles, cousins live near your home?
(1) Yes _____ (2) No _____
12. Approximately how often did you visit your family members who
lived outside your home?
(1) Daily _____ (2) Weekly _____ (3) Monthly _____ (4) Once
a year or less _____ (5) Never _____
13. Was your original family name changed?
(1) Yes _____ (2) No _____
14. What is your religious preference?
(1) Catholic _____ (2) Jewish _____ (3) Protestant _____
(4) Denomination (5) Other _____ (6) None _____
15. Is your spouse the same religion as you?
(1) Yes _____ (2) No _____
16. Is your spouse the same ethnic background as you?
(1) Yes _____ (2) No _____
17. What kind of school did you go to?
(1) Public _____ (2) Private _____ (3) Parochial _____
18. As an adult, do you live in a neighborhood where the neighbors
are the same religion and ethnic background as yourself?
(1) Yes _____ (2) No _____
19. Do you belong to a religious institution?
(1) Yes _____ (2) No _____
20. Would you describe yourself as an active member?
(1) Yes _____ (2) No _____
21. How often do you attend your religious institution?
(1) More than once a week _____ (2) Weekly _____
(3) Monthly _____ (4) Special holidays only _____
(5) Never _____
22. Do you practice your religion at home?
(1) Yes _____ (2) No _____
(If yes, please specify)
(3) Praying _____ (4) Bible reading _____
(5) Diet _____ (6) Celebrating religious holidays _____
23. Do you prepare foods of your ethnic background?
(1) Yes _____ (2) No _____
24. Do you participate in ethnic activities?
(1) Yes _____ (2) No _____
(If yes, please verify)
(3) Singing _____ (4) Holiday celebrations _____
(5) Dancing _____ (6) Festivals _____
(7) Costumes _____ (8) Other _____
25. Are your friends from the same religious background as you?
(1) Yes _____ (2) No _____
26. Are your friends from the same ethnic background as you?
(1) Yes _____ (2) No _____
27. What is your native language? _____
28. Do you speak this language?
(1) Prefer _____ (2) Occasionally _____ (3) Rarely _____
29. Do you read your native language?(1) Yes _____ (2) No _____
B O X 6 – 1 Heritage Assessment Tool
Source:

Note: The greater the number of positive responses, the greater the
person’s identification with a traditional heritage. The one exception
to positive answers is the question about family name change. This
question may be answered negatively.
1. Where was your mother born?____________________________
2. Where was your father born? ______________________________
3. Where were your grandparents born?
(1) Your mother’s mother?______________________________
(2) Your mother’s father? ______________________________
(3) Your father’s mother? ______________________________
(4) Your father’s father? ________________________________
4. How many brothers _____ and sisters _____ do you have?
5. What setting did you grow up in? Urban _____ Rural _____
Suburban _____
6. What country did your parents grow up in?
Father _____
Mother _____
7. How old were you when you came to the United States? _____
8. How old were your parents when they came to the United
States? Mother _____ Father _____
9. When you were growing up, who lived with you? _____
10. Have you maintained contact with
a. Aunts, uncles, cousins? (1) Yes _____ (2) No _____
b. Brothers and sisters? (1) Yes _____ (2) No _____
c. Parents? (1) Yes _____ (2) No _____
d. Your own children? (1) Yes _____ (2) No _____
11. Did most of your aunts, uncles, cousins live near your home?
(1) Yes _____ (2) No _____
12. Approximately how often did you visit your family members who
lived outside your home?
(1) Daily _____ (2) Weekly _____ (3) Monthly _____ (4) Once
a year or less _____ (5) Never _____
13. Was your original family name changed?
(1) Yes _____ (2) No _____
14. What is your religious preference?
(1) Catholic _____ (2) Jewish _____ (3) Protestant _____
(4) Denomination (5) Other _____ (6) None _____
15. Is your spouse the same religion as you?
(1) Yes _____ (2) No _____
16. Is your spouse the same ethnic background as you?
(1) Yes _____ (2) No _____
17. What kind of school did you go to?
(1) Public _____ (2) Private _____ (3) Parochial _____
18. As an adult, do you live in a neighborhood where the neighbors
are the same religion and ethnic background as yourself?
(1) Yes _____ (2) No _____
19. Do you belong to a religious institution?
(1) Yes _____ (2) No _____
20. Would you describe yourself as an active member?
(1) Yes _____ (2) No _____
21. How often do you attend your religious institution?
(1) More than once a week _____ (2) Weekly _____
(3) Monthly _____ (4) Special holidays only _____
(5) Never _____
22. Do you practice your religion at home?
(1) Yes _____ (2) No _____
(If yes, please specify)
(3) Praying _____ (4) Bible reading _____
(5) Diet _____ (6) Celebrating religious holidays _____
23. Do you prepare foods of your ethnic background?
(1) Yes _____ (2) No _____
24. Do you participate in ethnic activities?
(1) Yes _____ (2) No _____
(If yes, please verify)
(3) Singing _____ (4) Holiday celebrations _____
(5) Dancing _____ (6) Festivals _____
(7) Costumes _____ (8) Other _____
25. Are your friends from the same religious background as you?
(1) Yes _____ (2) No _____
26. Are your friends from the same ethnic background as you?
(1) Yes _____ (2) No _____
27. What is your native language? _____
28. Do you speak this language?
(1) Prefer _____ (2) Occasionally _____ (3) Rarely _____
29. Do you read your native language?
(1) Yes _____ (2) No _____
B O X 6 – 1 Heritage Assessment Tool
Source:

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