Example diversity questionnaire

This example questionnaire is provided by the Public Sector Commission to assist organisations in
collecting diversity information from their employees. Please note diversity information collected
from staff should be based on self-nomination and disclosure. Under no circumstances should
assumptions be made about the cultural background, gender identity or disability status of
employees on their behalf.
For information about diversity reporting, see the Commissions website at
www.publicsector.wa.gov.au, phone (08) 6552 8862 or email [email protected].
Why do we need this information?
We need a diverse workforce in this organisation so that we can:
meet the diverse needs of the community that we serve, and
provide equal opportunity for all people in public employment.
This questionnaire provides us with important information on the diversity of our workforce that
helps us assess how well we are achieving these outcomes. It will be used to inform and develop
organisation and government policies and programs relating to employment and service delivery.

Confidentiality
Maintaining the confidentiality of your personal information is of utmost concern to us. This
information will be held in confidence on our personnel system and will only be used for the
purpose of developing equal employment opportunity and diversity policies and programs for the
organisation and for government.

It is not compulsory for you to disclose your diversity status.

Should you have any questions, please contact [insert contact name] on [insert phone number] or
via email to [insert email address].

Instructions
The questionnaire will take approximately five minutes to complete.
Information about your cultural background, gender identity and disability status is important to us.
Please answer all questions. If you have a particular reason for not wanting to answer a question,
leave that question blank, but please answer the other questions and return the form.
Once you have completed the questionnaire please return it to:

[insert agency representative

and collection point]

The questionnaire should be returned by [insert return date]

 Example diversity questionnaire
Last name: Employee identifier:

First name:

1 Do you identify as male, female or 5 Do you speak a language other than

indeterminate/ intersex/ unspecified ? English at home?
Note: If more than one language is spoken, indicate
Male........................................ the one spoken most often.

Female.
No, English only................
Indeterminate/ intersex/ unspecified .
Yes, Arabic........................
2 What is your date of birth? Yes, Afrikaans...................

Yes, Cantonese.................

day month year Yes, Filipino.......................

3 In which country were you born? Yes, French.......................

Yes, German.....................
Australia.................................
Yes, Hindi..........................
Canada.................................. Yes, Indigenous Australian
language ......................
language...................
England.................................

Ireland.................................... Yes, Indonesian.................

Yes, Italian.........................
New Zealand..........................
Yes, Malay.........................
Northern Ireland.....................
Yes, Mandarin...................
Scotland.................................
Yes, Polish........................
South Africa...........................
Yes, Spanish.....................
United States of America.......
Yes, Tagalog......................
Wales.....................................
Yes, Vietnamese...............
Other (please specify)
Yes, other
(please specify)

4 Are you of Aboriginal and/or Torres Strait

Islander origin?
No..........................................

Yes, Aboriginal.......................

Yes, Torres Strait Islander......

6 Do you have any of the following 7. Does your
ongoing disabilities? disability require adjustments in the
Note: This includes anyone with an ongoing workplace by us?
disability who has an employment restriction due to Note: Examples include modifications to:
their disability that requires any of the following: the tasks of the job or the working hours
restriction in the type of work they can
the workplace, work area or equipment
do
provide extra time for some tasks
modified hours of work or time schedules
provide extra assistance or supervision.
adaptations to the workplace or work
area
specialised equipment Yes .
extra time for mobility or for some
tasks No ...
You do not need to answer any further
ongoing assistance or supervision to carry out questions
their duties.

8. Please describe
Sight.......................................... the adjustments we need to make to your
Use Braille, low vision aids or other workplace and indicate which of these
special technology such as appropriate have been provided:
computers or screens (Note: Does not
include glasses or contact lenses). Adjustments needed Provided
(Yes/No)
Speech......................................
Use aids such as word processors or
communication boards in order to be
understood or need extra time to be
understood.

Hearing......................................
Use aids such as a hearing help card
or volume control telephone in order
to hear or TTY (telephone typewriter),
Auslan interpreter, or note taker in
order to communicate.

Learning.....................................
Use specific support and training to
perform the job, need more than
average time to learn some parts of a
job or have difficulty reading or writing
e.g. have an intellectual disability,
acquired brain injury or dyslexia. 9. If you provided
Use of arms or hands...............
an answer at Q8, would you like this
Use specific equipment e.g. modified
information to be made available to
keyboard, hands-free telephone or appropriate staff so any adjustments can
need extra time for handling objects. be put in place and maintained?
Use of legs................................. Note: Your answers to other questions will remain
confidential.
Use aids or need extra time for
mobility e.g. wheelchair, crutches. Yes............................................

No..............................................
Any long-term health or medical
condition which regularly restricts or
limits activities e.g. requires regular
absences due to illness or time to be Thank you for your participation in
provided at work for medication or this questionnaire.
treatment or restricts some functions
due to health and safety considerations.
Other
(please specify)