Discrimination Questionnaire Form

A discrimination questionnaire form is a form used in an organization and is filled up by an individual who feels that he is a victim of discrimination. There are various kinds of discrimination questionnaire form depending upon on the kind of discrimination the victim faces. These types of forms include the personal details of the person filling the form and details of discrimination.

Sample Discrimination Questionnaire Form

SEXUAL ORIENTATION DISCRIMINATION QUESTIONNAIRE FORM

Name: _________________                             Date of filling the form: ______________

Address: _____________ Street address, _____________ City _____________ State __________ Zip code

Mobile number: __________

Email id: _____________

1. What is your date of joining the organization?

_______________________

2. Give details of the discrimination that took place in the organization against you and why do you think you were a victim of it?

_______________________

3. What kind of discrimination do you think you were victim of?

a)   Direct sex   discrimination

b)   Indirect sex   discrimination

c)   Victimization

4. According to which provision of the law do you think you have suffered?

_________________
Do you agree that the treatment against you was unlawful?

a)   Strongly agree

b)   Agree

c)   Somewhat agree

d)   Disagree

5. What reason did your superior give for such mistreatment?

_______________

6. Who was consulted for this decision against you and what were their views?

____________________

7. Was your superior able to clarify his decision?

a)   Yes

b)   To a certain extent

c)   No

8. What were the steps taken and the persons involve in the organization to investigate on this matter?

___________

Signature of the victim: ______________