Person Affected Questionnaire

Is your immediate physical and/or emotional safety a concern?This includes physical, and extreme emotional abuse. no matter how minor it may appear to others.

YESNO

IF YOUR IMMEDIATE PHYSICAL OR EMOTIONAL SAFETY IS A CONCERN:

Please exit this questionnaire and call 911 if in physical danger.

If you are in immediate emotional danger (physical symptoms), please contact People@TheEquityConsortium.com or text (206) 303-8978 immediately.

OPTIONAL: If you'd like us to contact you with options of relief or simply someone to listen, please share your name and preferred method of contact below.You are absolutely NOT obligated to follow up in any way. Sometimes, a story just needs to be told and heard.

Your Full Name

Your Email (regularly checked)

Phone Number

Would you like us to contact you to follow up with options of relief?You are absolutely NOT obligated to follow up. Sometimes, a story just needs to be told.

YESNO

We ask about timing. Did the reason for you reaching out today happen within the last three months?Don't worry if it's been more than three months. This question helps us find appropriate resources if requested.

YESNO

Over the last three months, how often has the reason that brought you here occurred?Feel welcome to include more details in a few moments.

1 Time

2 Times

3 Times

4 Times

5 or more times

Other

Please select any options below that could describe the reason for you reaching out today.Your reason does NOT need to be connected to your demographic identity (i.e. race, gender, sexual orientation, religion, physical/mental abilities, etc).

Discrimination

Harassment

Intimidation

Retaliation

None of the Above

Other

You indicated you are experiencing discrimination and/or "other". Please select any that may describe your identity as it related to your visit today. OPTIONALPlease feel welcome to use the "Self-Describe" field to share your identity in your own words.

Racial / Ethnic

Sexual Identity Expression

Gender Identity

Age (Youth or Elder)

Religion

Class / Caste

Parental Status

Physical Disability

Neurodivergence

Other

You indicated you are experiencing intimidation, harassment, and/or "other". Below are several indicators based on lived experiences. Please select any/all that apply to your experience.This is NOT an exhaustive list of lived experiences. We encourage you to add yours with the "And" option.

Questioning credentials, intellect, expertise, and/or capacity without evidence

Unsolicited comments / conversations regarding one’s identity(ies) and/or culture

Patronizing / consistently over-explaining

Consistent aggression for no discernable reason

Consistently interrupting or not allowing one to speak

Speaking disparagingly about someone to others (marginalization), or in public

Not allowing or interfering with others reasonably socializing

Consistently assigning less favorable tasks

Not giving proper credit to work products

Removal and/or addition of duties and responsibilities without justification

Aggressively not allowing for mistakes or human error

Invading personal space

Unreasonable and/or unfair expectations around time allowances

Violating confidentiality

Involving unnecessary people in conflict

Other

Is the person or persons you identify a supervisor or in a position higher than yours?It is NOT necessary that the person(s) be supervisory. This question helps us understand power dynamics.

YESNO

Now, In Your Own Words.

To help us understand the facts and timeline, please share as many details as you're comfortable. We welcome both organized and not-yet organized stories.

While not required, if your story involves your or others' demographics (race, ethnicity, gender, sexual orientation, physical/mental abilities, etc) please include demographic information in your own words.

Please use non-identifying language such as "Person A".

Also we ask, "What do you need for this to feel resolved?" This is NOT required, but helpful not only for us, but for you.

Breathe.

Again.

We're listening.

What brings you here today? What will help understand your experience?We value your confidentiality and do not share your information or contact anyone without your permission.

Person Affected Questionnaire