Diversity Feedback Questionnaire

DIVERSITY FEEDBACK QUESTIONNAIRE AND ENGAGEMENT AGREEMENT

This Diversity Feedback Questionnaire and Engagement Agreement (the Agreement) is made between Organization Name: and Respondent Name: . Effective Date:

Recitals

WHEREAS, Organization Name: seeks informed, structured feedback from stakeholders to assess diversity, equity, and inclusion initiatives and to inform organizational improvements;

WHEREAS, Respondent Name: has relevant experience and perspective and is willing to provide feedback subject to the terms set forth in this Agreement;

WHEREAS, the parties desire to document the scope, use of submitted feedback, confidentiality obligations, and related administrative terms;

Scope of Work

Diversity Feedback Questionnaire

Demographic Information (Optional)

Native or Indigenous Asian Black or African Descent Hispanic or Latino

White Middle Eastern / North African Other Prefer not to say

Female Male Non-binary Prefer not to say

I identify as having a disability I do not identify as having a disability Prefer not to say

Experience and Perception

Please rate the following statements on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

I consent to the organization using my feedback with attribution to my name. I prefer my feedback be used only in anonymized or aggregated form. I withhold consent for any external use beyond internal analysis.

Payment Terms

Term and Termination

Term Start Date:   Term End Date:

Confidentiality

All feedback provided by Respondent that is designated as confidential or that, by its nature, should reasonably be regarded as confidential shall be held in strict confidence by Organization and its affiliates. Confidential information shall not be disclosed except to those employees, contractors, or advisors who have a need to know and are bound to confidentiality obligations no less protective than those set forth herein. This obligation shall survive termination of this Agreement for a period of years, except where longer retention is required by law.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles. Any dispute arising out of or relating to this Agreement shall be subject to the exclusive jurisdiction of the state and federal courts located within that state.

Entire Agreement

This Agreement, together with any written attachments or exhibits expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, whether written or oral. No amendment to this Agreement shall be effective unless in writing and signed by authorized representatives of both parties.

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