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):

Racial Discrimination Reporting

Who demonstrated this act of racial discrimination? Please select all that apply.
Were there other witnesses to this racial discrimination? Please select all that apply.
How often do you experience and/or witness racial discrimination?*
If applicable, how was this incident addressed? Please select all that apply.
If you attempted to address the incident, did you feel the problem was resolved?
Was there a follow-up?

Demographic Information

What is your age?*
How do you self identify your race/ethnicity? Please select all that apply.*
Are you comfortable with the MNA Racial Diversity Committee sharing your story anonymously for educational purposes?*
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.*
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