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Do you feel your work environment creates barriers that make success harder than it should be, even if you believe you can overcome them?
Yes
No
Not Sure
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Are you the only person experiencing unfair treatment or are there others?
*
You are the only one targeted
You and others are targeted
Everyone is receiving an equal level of unfair treatment
Other
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Are any of the following characteristics unique to you when compared to your peers?
Race or Ethnicity
Color
National Origin
Religion
Gender or Gender Identity
Sexual Orientation
Pregnancy
Disability
Genetic Information
Age (40 or older)
Are any of the following characteristics unique to the members of the group experiencing unfair treatment?
Race or Ethnicity
Color
National Origin
Religion
Gender or Gender Identity
Sexual Orientation
Pregnancy
Disability
Genetic Information
Age (40 or older)
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Does the unfair treatment you've experienced include inappropriate comments, jokes or questions referencing common stereotypes or bias about your identity?
*
Yes
No
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Who is the primary person participating in or initiating the unfair treatment?
*
Direct Supervisor / Manager
Leadership - Other (example: skip-level leader, department head, company executive)
HR or People Team
Co-worker or peer
Client or customer
Other
Do you feel increased anxiety and stress when a work day requires interaction with this person?
Yes
No
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Did you inform your supervisor or HR about the unfair treatment?
Yes
No
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Has the unfair treatment resulted in any of the following?
Assigned less favorable projects and opportunities
Higher level of scrutiny or criticism for your work
Public criticism and complaints about your work
Removed from or left out of meetings and invites when you should be included
Reduction in responsibility or visibility, formally or informally
How long have you been concerned about unfair treatment?
*
Less than a month
Less than 3 months
Less than a year
At least 1 year
How has the unfair treatment impacted your career?
Promotion Denial / Demotion
Inadequate Compensation (Compared to Peers)
Threat of Termination
Termination
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