Diversity Questionnaire


Diversity questionnaire is a set of questions which is designed to examine the ethnic, social and cultural diversity of an institution or workplace. It is done so with the intention of incorporating maximum diversity into the workforce which enables the company or organization to expand its clientele/ consumers among diverse demography. It is also a mark of how an organization can pursue higher standards of social and cultural values. It is noteworthy that diversity also includes physically challenged people, people with diverse sexual orientation etc.

Diversity Questionnaire Sample

Name:               _________________________________________________________________

Age:          _________________________      Gender:     _______________________

  1. In my company I work as a:            __________________________________________
  2. I am born in :-

a) USA                       b) West Europe   c) Scandinavia/ Nordic countries

d) Eastern Europe                e) Latin America  f) South America g) Middle East

h) Indian Subcontinent i) Australia or Oceania                 j) Africa

k) Caribbean                       l) China / Japan

m) Other    ____________________________________________________________

  1. At my home I speak

a) English only    b) other language which is ________________________________

  1. Other than English I am fluent/ can understand the following languages

________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. At my place employees of all ethnicity, races and religions are treated equally (Y/N) : __
  1. Do you have any physical disability which affects your work (Y/N)? :     ____________

In case answer to the above question is “NO”, you can skip the following questions otherwise continue

  1. How does your disability affect your work?
  2. Restricts movement which is required
  3. Workplace adaptations required
  4. I cannot take the strain/workload that others can
  5. Specialized equipment
  6. Modified hours of work
  7. Extra time for mobility
  8. Need assistance from others
  1. Which aspect of your body is physically challenged?
  2. Sight
  3. Hear
  4. Speech
  5. Arms
  6. Legs
  7. Learning capability
  8. Psychiatric
  9. Other(specify) :  ________________________________________________
  1. Do you find that the organization assists in modifying the workplace for your convenience?

Category: Medical Questionnaire

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