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This template is a suggested form and is provided "as-is" without any warranty of any kind. It is provided for general informational purposes only and should be modified by you or your attorney to meet your specific needs and any applicable legal requirements. You are responsible for complying with your organization’s privacy policies and any privacy obligations related to collecting sensitive personal data.

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* 1. What is your gender identity?

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* 2. Do you identify as transgender or non-binary?

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* 3. What is your sexual orientation?

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* 4. What is your racial or ethnic identity? (Select all that apply.)

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* 5. Do you have a disability?

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* 6. How old are you?

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* 7. What is the primary language you speak at home?

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* 8. Are you a primary caregiver for any of the following people? (Select all that apply)

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* 9. Do you consider yourself a first generation college graduate?

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* 10. Have you ever served in the military?

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* 11. Which best describes your current work arrangement?

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* 12. Are you involved in an employee group at work based on any of the following? (Select all that apply)

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* 13. Are you interested in being involved in an employee group at work based on any of the following? (Select all that apply)

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* 14. Which function do you work in?

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