1. How many times in your life have you been discriminated against in each of the following ways because of such things as your race, ethnicity, gender, age, religion, physical appearance, sexual orientation, or other characteristics?

a. You were discouraged by a teacher or advisor from seeking higher educaiton?

b. You were denied a scholarship?

c. You were not hired for a job?

d. You were not given a job promotion?

e. You were fired?

f. You were prevented from renting or buying a home in the neighborhood you wanted?

g. You were prevented from remaining in neighborhood because neighbors made life so uncomfortable?

h. You were hassled by the police?

i. You were denied a bank loan?

j. You were denied or provided inferior medical care?

k. You were denied or provided inferior service by a plumber, car mechanic, or other service provider?

2. What was the main reason for the discrimination you experienced?

a. Your age

b. Your gender

c. Your race

d. Your ethnicity or nationality

e. Your religion

f. Your height or weight

g. Some other aspect of your appearance

h. A physical disability

i. Your sexual orientation

j. Other

3. Overall, how much has discrimination interfered with you having a full and productive life?

a. A lot

b. Some

c. A little

d. Not at all

4. Overall, how much harder has your life been because of discrimination?

a. A lot

b. Some

c. A little

d. Not at all