Culture Checklist Sample

My Students’ Ethnicities

Hispanic

  • Mexican
  • Puerto Rican
  • Cuban
  • Dominican
  • Honduran
  • Spanish
  • Portuguese
  • Peruvian
  • Other: ____________

Black

  • African American
  • Jamaican
  • Haitian
  • Egyptian
  • Somalian
  • Nigerian
  • West Indies
  • Other: ____________

White

  • Irish
  • Scottish
  • German
  • English
  • French
  • Italian
  • Australian
  • Canadian
  • Other: ____________

Asian

  • Chinese
  • Japanese
  • Korean
  • Cambodian
  • Viet Namese
  • Korean (N & S)
  • Indonesian
  • Pacific Islander
  • Other: ____________

Middle Eastern

  • Iranian
  • Iraqui
  • Syrian
  • Kuwaiti
  • Afghani
  • Indian
  • Israeli
  • Other: ____________

My Students’ Religious Affiliations

  • Jewish
  • Christian
  • Russian Old Believers
  • Catholic
  • Other: ____________
  • Hindu
  • Muslim
  • Buddhist
  • Other: ____________

My Students’ family structures

  • 2 parent home
  • Incarcerated parent(s)
  • Migrant
  • 2 parents + extended family
  • Living with grandparents
  • Other: ____________
  • Same sex parents
  • Foster Home
  • Separated parents, shared custody
  • Adopted
  • Separated parents, single custody
  • Homeless

My students’ special needs or significant characteristics

  • English Language Learner
  • Trans-gender
  • Autistic
  • ADHD
  • Gay
  • Traumatized
  • Deaf or Hearing Impaired
  • Blind or severe sight limitations
  • Developmental Delay
  • Behavioral Issues
  • Physical Limitations