B.L.A.C.K Survey (Black. Legal. Action. Community. Knowledge)

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Contact Information

First Name Last Name

Race

Street Address (Optional)

Postal Code City State

Email Mobile Phone

Remember me so that I can use FastAction next time.

(Optional)

Employer

Occupation

I am retired

Additional Information

Date of Employment

How would you describe your work experience?
How would you describe your work experience? is required.

Low wage worker

Underemployed

Unemployed

Gig worker

Self employed

Manage/ Director

Formerly Incarcerated

What types of issues are you experiencing at work?
What types of issues are you experiencing at work? is required.

Unpaid wages

Lack of overtime

Race Discrimination

Sexual harassment

Unfair termination

Unsafe Working Conditions

Workplace Injury

No Paid time off

No healthcare benefits

No health & safety trainings or equipment

Lack full-time job that pay living wages

No opportunities for promotion

No HR department

None

What action do you want to take? (Optional)
What action do you want to take? is required.

Learn about legal rights

Take legal action

Share your experience to help raise awareness

Work with your coworkers to take action to change conditions in the workplace

Participate in shaping policy

Other

Anything else you'd like to share about working while Black ?

Can we contact you to learn more?
Can we contact you to learn more? is required.

Yes

No

Would you be interested in being connected with an attorney if you are experiencing a legal issue. Note: This does not guarantee a call from our legal team or create an attorney-client relationship.

Other Comments (Optional)

Do we have your permission to share your information with our legal partners?
Do we have your permission to share your information with our legal partners? is required.

Yes

No

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