Questions for Questionbank - Equity ICR November 2022

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QUESTIONS – EQUITY ICR QUESTION BANK

Demographic Questions

Section 1: Name

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Nickname or Preferred Name:

Current Affiliation/Employer:

Section 2: Personal Information

Age at date of application: ______________

Q: What sex were you assigned at birth?

A: (check one)

• Male

• Female

• Intersex

• Prefer not to answer

Q: How do you currently describe yourself?

A: (check one)

• Male

• Female

• Non-binary

• Transgender

• Other/Self-Identify (fill in the blank)

• Prefer not to answer

Q: Which of the following best represents how you think of yourself?

A: (check one)

• Lesbian or Gay

• Straight

• Bisexual

• Other/Self-Identify (fill in the blank)

• I do not know the answer

• Prefer not to answer

Are you of Hispanic, Latino, or Spanish origin?

• No, not of Hispanic, Latino or Spanish origin

• Yes, Mexican, Mexican Am., Chicano

• Yes, Puerto Rican

• Yes, Cuban

• 
  Yes, another Hispanic, Latino, or Spanish origin –Print origin, for example, Argentinian, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.

What is your race? Mark X one or more boxes.

• White

• Black or African Am.

• American Indian or Alaska Native – Print name of enrolled or principal tribe.

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• 
  Other Asian- Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

• 
  Other Pacific Islander- Print race, for example, Fijian, Tongan, and so on.

• 
  Some other race- Print race.

Q: Which Categories describe you best?

A: (check all that apply)

• White/Caucasian descent (For example, German, Irish, English, Italian, Polish, French, etc.)

• Hispanic or Latin American descent (For example, Spanish, Portuguese, Mexican or Mexican American, Puerto Rican, Cuban, Salvadorian, Dominican, Colombian, etc.)

• Black, African American, African, or Afro Caribbean descent (For example, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc.)

• Asian descent (For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, Okinawan, etc.)

• Native American or Alaska Native descent (For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc.)

• Middle Eastern or North African descent (For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, Israeli/Jewish, Palestinian etc.)

• Native Hawaiian or Pacific Islander descent (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, Palauan, Yapese, Chuukese, Pohnpeian, Kosraean, etc.)

• Other/Self-Identify (fill in the blank)

• Prefer not to answer

Q: Disability Status Long-lasting or chronic condition (physical, visual, auditory, cognitive or mental, emotional or other) that substantially limits one or more of your major life activities (your ability to see, hear, or speak; to learn, remember, or concentrate):

A: (check all that apply)

• Intellectual or learning difference

• Mobility/Orthopedic impairment

• Psychiatric condition

• Visual impairments

• Hearing impairments

• Neurological disabilities

• Chronic illness

• Other/Self-Identify (fill in the blank)

• None

• Prefer not to answer

Q: Citizenship Status:

A:

• US Citizen

• Permanent Resident

• Other non-US Citizen

• Prefer not to answer

Q: What generation of American are you?

A:

• 1st Generation (Parents/Guardians were immigrants to the U.S.)

• 2nd Generation (Grandparents were immigrants to the U.S.)

• 3rd Generation (Great grandparents were immigrants to the U.S.)

• 4th Generation or more (Great, great grandparents or before were immigrants to the U.S.)

Q: Do you speak a language other than English at home?

A:

• Yes

• No

Q: What language(s) other than English do you speak at home?

A: (print below)

Q: How well do you speak English?

A: (check one)

• Very well

• Well

• Not well

• Not at all

Section 3: Career Path Information

Q: Career Stage:

A: (check all that apply)

• Student (Currently enrolled in any degree program)

• Early Career (Up to ten years past your terminal degree)

• Mid-Career (Ten+ years past terminal degree and pre-retirement)

• Retired/Emeritus

• Other/Self-Identify (fill in the blank)

• Prefer not to answer

Q: Highest Degree Earned:

A: (check one)

• High School or Equivalent

• Associate Degree

• Bachelor Degree

• Master Degree

• Doctorate Degree

• Other/Self-Identify (fill in the blank)

• None

• Prefer not to answer

Q: First Generation College Student/Graduate:

A: (check one)

• Yes (Parent(s) have NOT earned a bachelor's (or higher) degree)

• No (Parent(s) have earned a bachelor's (or higher) degree)

• Unsure (Do not know if parent(s) have earned a bachelor's (or higher) degree)

• Prefer not to answer

Q: Veteran Status:

A: (check one)

• Active Duty

• Reservist

• Veteran

• Not a Veteran

• Prefer not to answer

Section 4: Questions to Assess Social Vulnerability Status

Q: Access to motor vehicle:

A:

• Yes

• No

Q: Single-parent household ("no spouse present"):

A:

• Yes

• No

Q: Primary residence in multi-unit structure:

A:

• Yes

• No

Q: Primary residence in mobile home:

A:

• Yes

• No

Q: Primary residence in group quarters (e.g., prisons, nursing homes, college dormitories, and military quarters):

A:

• Yes

• No

Q: Open ended questions:

State of residence: _______________

Annual household income: _______________

Total number of persons in household: ________________

Number of persons in household aged 65 or older: ________________

Number of persons in household aged 17 or younger: _____________

Number of persons over age 5 with a disability: ________________

Number of persons in household who speak English "not well" or "not at all": ______________

Number of rooms in residence: _________________

Section 5: Business Questions

Is your company (check all that apply):

• Woman-owned (Organization is at least 51% owned, operated, and controlled by a minimum of one U.S. citizen whose gender is female)

• Veteran-owned (Organization is at least 51% owned, operated, and controlled by a minimum of one U.S. citizen who has served or currently serving in the U.S. armed forces)

• Minority-owned (Organization is at least 51% owned, operated, and controlled by a minimum of one U.S. citizen whose ethnic background is at least 25% Asian-Indian, Asian-Pacific, Black, Hispanic, or Native American)

• Disabled-owned (Organization is at least 51% owned, operated, and controlled by a minimum of one U.S. citizen who is disabled as defined by the Americans with Disabilities Act)

• None of the above / Don’t know

If respondent selects Minority-owned, ask the following question:

Please select the racial category or categories with which you most closely identify. (Mark all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic

• Native Hawaiian or Other Pacific Islander

ADDITIONAL QUESTIONS

Using the definitions below we are requesting customer input on the following questions where applicable:

The term “equity” means the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.

The term “underserved communities” means populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the preceding definition of “equity.”

• Have you applied for or accessed DOC/BUREAU programs and services in the past? If so, please describe your experience.

• Have you had difficulty accessing one or more DOC/BUREAU programs? If so, which ones? Please explain the difficulty.

• How can DOC/BUREAU better share information with underserved populations about our programs and services?

• Please describe DOC/BUREAU programs or interactions that have worked well for underserved communities.

• What are the best ways to notify and engage underserved populations about new programs and services or changes to existing services?

• Describe your experience(s) interacting with DOC/BUREAU staff when trying to access DOC/BUREAU programs and services.

• Are DOC/BUREAU agency websites helpful in providing useful information on programs and services, explaining how specific programs and services work, and explaining how applications for participation are considered? What are areas for improvement?

• What are the barriers to applying for our grant programs?

• How can DOC/BUREAU make grant processes easier to understand and more accessible to underserved groups?

• How can our agency make it easier for you to apply for a grant?

• What tangible benefits, if any, is your community receiving from the program?

• How can our program better serve your community?

• Have you experienced injustice, inequity, or unfairness in one or more DOC/BUREAU programs? If so, which ones? Please explain the situation(s).

• Are there DOC/BUREAU policies, practices, or programs that perpetuate systemic barriers to opportunities and benefits for underserved groups?

• How can those programs be modified, expanded, or made less complicated or streamlined, to deliver resources and benefits more equitably?

• How can DOC/BUREAU establish and maintain connections to a wider and more diverse set of stakeholders representing underserved communities?

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