Action Network

Personal Information

Equity Declaration

1. What is your gender?

Agender

Genderqueer or Gender Fluid

Man

Non-Binary

Two-Spirit

Woman

Another gender

Prefer not to say

2. Are you an Indigenous person?

For the purposes of this form, the term “Indigenous” mean persons First Nation with or without Status or non-Status, Inuk, or Métis (Michif, Scrip).

Yes No Prefer not to say

If yes, check all that apply

First Nation

Inuk (Inuit)

Metis

Name of First Nation, Metis Organization or Inuit Organization that you are from:

I am not a registered member of any of the above. Details below:

3. Are you a person with a disability?

As defined by the Accessible Canada Act, a person with a disability is a person with “...any impairment, including a physical, mental, intellectual, cognitive, learning, communication or sensory impairment — or a functional limitation — whether permanent, temporary or episodic in nature, or evident or not, that, in interaction with a barrier, hinders a person’s full and equal participation in society. This definition encompasses a broad range of impairments, whether permanent, temporary, or episodic, and whether visible or invisible.”

Yes No Prefer not to say

If yes, check all that apply:

For the purposes of this questionnaire, please identify all disabilities that affect your full participation in society, either permanently or temporarily, visibly or invisibly, mildly or severely.

Prefer not to specify

Speech disabilities - These disabilities affect the ability to produce sounds to create words and communicate verbally with other people. Some examples include ataxia, dysarthria, verbal apraxia, or total speech loss.

Mobility, flexibility, and dexterity disabilities - A mobility disability affects how you move your body, including walking or using stairs. Challenges with flexibility or dexterity affect the ability to move joints or perform motor tasks, especially with your hands. Examples include amputations, multiple sclerosis, Parkinson’s disease, cerebral palsy, and spinal cord injuries.

Hearing disabilities - A hearing disability affects how well, or if at all, a person can hear. These disabilities make it difficult for a person to hear when there is background noise or if there are many different sound sources. Examples include deafness, hard of hearing, and acoustic distortions.

Mental health disabilities - These disabilities are often invisible or hidden and can affect a person’s physical health, thoughts, feelings, energy levels, and sensations. Some examples include anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, or schizophrenia.

Vision or seeing disabilities - A seeing disability affects how well a person sees, or whether they see at all. Examples of seeing disabilities include sensitivity to light, blindness, low vision or partial sight, legal blindness, deaf blindness, and colourblindness.

Chronic conditions and pain-related disabilities - These disabilities can affect the quality of day-to-day life, either on a regular or episodic basis. Many of these disabilities are invisible or hidden and can include environmental/allergen sensitivities, arthritis, migraines, sickle cell disease, traumatic injuries, Crohn’s disease, colitis, fibromyalgia, and multiple sclerosis.

Learning disabilities - These disabilities make it difficult for people to learn, read, or process information, including challenges with organization, time management, or writing. Examples include dyslexia, attention deficit / hyperactivity disorder, executive function disorders, and dyscalculia.

Developmental disabilities - People with these disabilities often face difficulty communicating or understanding written or spoken language, including difficulties with learning, reasoning, decision-making, or problem-solving. Developmental disabilities sometimes overlap with learning disabilities and can include epilepsy, autism spectrum disorder, Down syndrome, and fetal alcohol spectrum disorders.

Memory disabilities - These disabilities cause challenges when processing or retaining information, and can also include impairments to recognizing faces, bodily movements, or emotional responses. Some examples include stroke, encephalopathy, or dementia.

Not listed above

Optional to specify:

4. Are you racially visible or a racialized person?

If you identify solely as belonging to the Indigenous groups specified in question 2, please skip this question and complete question 2 only.

*Race is a social construct used to classify people into groups based principally on physical traits such as skin colour and physical characteristics. Racial categories are not based on science or biology but on differences society has created, with significant consequences for people’s lives. Racial categories may vary over time and place and can overlap / intersect with ethnic, cultural or religious groupings. 

Yes No Prefer not to say

If yes, are you are member of one or more of the following racialized groups? Check all that apply:

Black, (for example, Caribbean, African, person of African-Descent, etc.)

East Asian, (for example Chinese, Japanese, Korean, a person of East Asian descent, etc.)

South Asian/East Indian (for example Indian, Pakistani, Bangladeshi, Sri Lankan, person of South Asian descent, etc.)

Southeast Asian, (for example, Thai, Vietnamese, Burmese, Cambodian, Laotian, Filipino, Singaporean, person of Southeast descent, etc.)

Non-white West Asian, North African, or Arab (for example Egyptian, Libyan, Lebanese, person of non-white West Asian, North African or Arab descent, etc.)

Non-white Latin, Central and South American (for example, Indigenous, Black, person of Latin, Central and/or South American descent, etc.,)

Persons of Mixed Origin (with one parent in at least one of the groups listed above)

Another racially visible or racialized identity.

Optional to specify:

5. Are you a member of the 2SLGBTQIA+ community? (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Indigiqueer, Asexual, Pansexual)

Yes No Questioning Prefer not to say

If yes, check all that apply

Two-Spirit

Lesbian

Gay

Bisexual

Transgender

Questioning

Intersex

Indigiqueer

Asexual

Pansexual

Another identity

Optional to specify:

Prefer not to specify

Additional Information: 

Are you a young worker? (35 years old and under)

Yes No

If "Yes", please provide year of birth *

Month (optional)

Day (Optional)

Do you have a religious affiliation? Check all that apply:

Buddhism

Christianity

Hinduism

Islam

Judaism

Sikhism

Traditional (North American Indigenous) spirituality

Other religions and spiritual traditions.

No religion or secular perspective

Prefer not to say

Confidentiality and Consent

PSAC values your privacy and is firmly committed to protecting and safeguarding your personal information. The information collected will only be used at an aggregate level to develop programs and strategies that address membership needs. You may amend, correct, or revise your information at any time.

You may use my self-id data for statistical purposes. * Yes No

Authorization to share your contact information with different structures of the union in support of human rights work.

This information is kept confidential and collected and securely stored for planning purposes. You may request to amend it at any time. Please note that this information may be shared within different structures of the union, including staff and elected union representatives, in support of our human rights work only including event planning and communications. The sharing of members’ contact information is done in compliance with the PSAC Privacy and Confidentiality policies.

Please add my name and contact information to one or more of our respective PSAC equity and young worker contact lists. * Yes No

Equity Declaration Form (Voluntary)

Equity Declaration Form

Personal Information

Equity Declaration

Additional Information:

Confidentiality and Consent