Employment Discrimination Questionnaire

An employment discrimination questionnaire refers to the document which an individual in the work force of the company has to fill in when he or she is facing any discrimination at the hands of the employer. The questions in the questionnaire help in assessing the type of discrimination (sex discrimination, age discrimination, race discrimination etc.) and help the respective authorities take the required action to improve the situation.

Sample Employment Discrimination Questionnaire

Fill in the following blanks and answer the questions:

Full name:

Your date of birth:

Social Security Number

Correspondence Address:

Telephone No.:

Mobile No.:

Work Phone No.:

1. Provide the name of the organization where you are employed.


2. Give specification of your current job position at the organization and how long you have been employed in this company?


3. Do you think that you have been made a victim of some kind of employment discrimination at your workplace?

a) Yes

b) No

4. What was your beginning pay at this job (hourly rates or the monthly/ yearly salary)


5. Over the working period have you had any increments? If the answer is no, then do you think that this has been because of discrimination?


6. Do you agree to the fact that you receive less pay than your comparators? Explain your reasons for agreeing or disagreeing with the statement.


7. Do you agree that the work you do is equal to your comparators? Explain the reasons for agreement or disagreement.


8. Do you believe that you are being discriminated against at work because of you gender? Explain how and why you believe so.


9. Do you believe that there has been any unlawful treatment of you at work on basis of your race? Explain or support your answer.


10. Do you think that you have been discriminated due to your sexual orientation?

a) Yes

b) No


Category: Employment Questionnaire

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