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This is an internal MNA reporting form. All recorded answers are confidential. Data from this form will be viewed, analyzed, and used for organizing purposes by MNA staff, appointed and elected leaders. The information anonymously gathered will be a critical first step needed to organize around creating an anti-racist workplace.

This form was made to be completed after every act of racial discrimination in the workplace.

Work Information

Name (leave blank if you prefer to submit this form anonymously):

First Name

Last Name

Where do you work?*

What unit do you work on?

Racial Discrimination Reporting

Describe this incident. Please be as detailed as possible:*

Who demonstrated this act of racial discrimination? Please select all that apply.

Co-worker/colleague Manager Patient Patient's family member

Other: Other Value

Please enter your co-worker's job title (e.g. RN, NA):

Were there other witnesses to this racial discrimination? Please select all that apply.

No one, it just happened between the people described in the incident Co-worker/colleague Manager Patient Patient's family member

Other: Other Value

How often do you experience and/or witness racial discrimination?*

Multiple times a shift Once a shift Once a week Once a month A few times a year

Other: Other Value

If applicable, how was this incident addressed? Please select all that apply.

Not applicable Spoke to Charge Nurse Spoke to Manager Spoke directly to the perpetrator (the person committing the act of discrimination against you) Had a conversation with MNA Staff Rep (Organizer or Labor Relations Specialist) Had a conversation with the MNA Chairs Had a conversation with my union steward I did not address the issue to a third party I filled out the Racial Discrimination Reporting Form

Other: Other Value

If you attempted to address the incident, did you feel the problem was resolved?

Yes No Other

If Other, please explain:

Was there a follow-up?

Yes No Other

If Other, please explain:

Demographic Information

What is your age?*

18 - 24 25 - 34 35 - 44 45 - 54 55 and older Prefer not to disclose

How do you self identify your race/ethnicity? Please select all that apply.*

American Indian or Alaska Native Asian Black or African American Hispanic, Latinx, or Spanish Origin Native Hawaiian or Other Pacific Islander White Other Prefer not to disclose

Are you comfortable with the MNA Racial Diversity Committee sharing your story anonymously for educational purposes?*

Yes No

Would you like to be connected with the MNA Racial Diversity Committee’s work? Your email address will not be associated with this form if you prefer to submit this form anonymously.*

Yes No

Please enter your personal email address:*

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