Discrimination Survey

Thank you for taking the time to complete our survey. We will be sharing the results of the survey in September. All survey responses will be kept confidential. You may remain anonymous in this survey, if you choose.


First name
Last name
What are your preferred pronouns? (Check all that apply) *
He/him/his
She/her/hers
They/their/theirs
Other
Street Address
City
County in Pennsylvania *

The questions related to age, race & ethnicity, sexual orientation, and gender identity are for demographic purposes only.

Age Range *
Under 18
18 – 29
30 – 39
40 – 49
50 – 59
60 and older
Race & Ethnicity (Check all that apply) *
White/Caucasian (Non-Latinx)
Latinx
African-American (Black, Brown, etc.)
Pacific Rim
Asian-American
Native American
Other
No response/Don’t want to say
I identify my sexuality as… *
Bisexual
Gay
Lesbian
Pansexual
Asexual
Demisexual
Heterosexual
Other (option not listed)
I identify my gender as… *
Cisgender female
Cisgender male
Transgender male to female
Transgender female to male
Gender non-binary
Genderfluid
Other (Option not listed)
Have you experienced discrimination or bullying in your school environment? *
Yes
No
Does not apply
If you answered yes, please explain how.
Have you experienced discrimination or bullying in your workplace environment? *
Yes
No
Does not apply
If you answered yes, please explain how.
Have you experienced discrimination based on your sexual orientation or gender identity or expression in public accommodations, such as lodging or transportation? *
Yes
No
Does not apply
If you answered yes, please explain how.
Have you experienced discrimination based on your sexual orientation or gender identity or expression when receiving medical care? *
Yes
No
Does not apply
If you answered yes, please explain how.
Have you experienced discrimination based on your sexual orientation or gender identity or expression in any governmental setting? *
Yes
No
Does not apply
If you answered yes, please explain how.
Have you experienced discrimination based on your sexual orientation, gender identity or expression under any other circumstances? *
Yes
No
Does not apply
If you answered yes, please explain how.

This concludes the survey. Thank you for your time. We will post results at the conclusion of the survey in September.