Discrimination Survey

Preferred Name (leave blank if you would prefer to write anonymously)

First Name

Last Name

E-mail (Leave blank if you would prefer)Emailing will allow us to clarify any details concerning your experience

What school do you attend?(please enter if you feel comfortable sharing)

What is your relationship with your school* This field is required.Select all that apply

Current Student

Admin/Faculty/Staff/Contractor

Former Student

None of the above

Would prefer not to say

Other

_____________ experienced discrimination.* This field is required.(please fill in the black

Someone else

Multiple people including myself

TMultiple people NOT including myself

On what grounds were you discriminated against?* This field is required.Please select all that apply

Race

Sexual Orientation

Gender

Creed/Religion

Gender Identity/Expression

Disability

Citizenship

Marital Status

Family Status

Age

Ethnic Origin

Place of Origin

none of the above

Would prefer not to say

On what grounds were they discriminated against?* This field is required.Please select all that apply

Race

Sexual Orientation

Gender

Creed/Religion

Gender Identity/Expression

Disability

Citizenship

Marital Status

Family Status

Age

Ethnic Origin

Place of Origin

none of the above

_______________ discriminated against you/your friend/etc.?* This field is required.Select all that may apply

A Professor

Admin (Office Workers)

A Staff (IT, Mail, etc)

Student

None of the above

Would prefer not to say

How long ago did your experience occur?

It is ongoing

Less than 2 months ago

between 2-6 months ago

between 6 months and 1 year ago

more than 1 year ago

Prefer not to say

Do you wish to share the name(s) of the person/people who discriminated against you/your friend?* This field is required.

YESNO

Please enter the names/position(s) of the party/parties you wish to disclose.

Please share (in as much detail as you feel necessary) how this experience made you feel. Please focus only on how it made you feel; You will have the opportunity in the next few questions to share the details of what occurred.* This field is required.SUGGESTIONS: Did you feel powerless? Embarrassment? Anger? Depression? Self-doubt? Dehumanized? etc. Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

Please share (in as much detail as you feel necessary) what happened.* This field is required.SUGGESTIONS: Writing chronologically and emphasizing details such as location, time of day, as well as consistent referencing of the individuals involved will make your story easier to understand. Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

How has this changed the way that you live your life?* This field is required.SUGGESTIONS: Have you lost trust for people? Do you feel anxiety or worry more? Has it made you stronger? If so how? Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

Did you take any action to obtain recourse?* This field is required.For example: Did you report the matter to any authorities? Or seek out an legal advice?

Yes

Prefer not to say

What was the reason you chose not to?

I had financial limitations

I had no time (schoolwork/employment/family demands etc)

I did not know what my options were

I was afraid of retaliation

I did not have enough evidence

It was too overwhelming for me/difficult to think about

I didn't want them to get in trouble

I did not want people I know to find out

Prefer not to say

What (if anything) do you think could have prevented your experience from happening?SUGGESTIONS: Better anti-discrimination campus policies? More cameras? Increased public education? Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

What advice (if any) or words of encouragement would you wish to share to someone experiencing something similar?SUGGESTIONS: Try to think of what you wish someone else would have told you or done for you during your experience? Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

Is there anything you wish to say to any of the parties involved in the matter?* This field is required.

YESNO

What would you like to say? Please feel free to use whatever formatting, emoticons/images/file uploads that may aid you in expressing.

Do you consent to your story being shared anonymously?**Though sharing your story can encourage others who have experienced similar challenges, your story is yours and will not be shared without your consent.

YESNO

Please enter an alias you'd like for us to use while sharing your story.(For your safety, please enter a name that is not indirectly traceable to you)

First Name

Last Name

Please verify that you are not a robot* This field is required.

Discrimination Survey