Academic Status (Check all that apply)
Exempt Staff
Non-Exempt Staff
Faculty
Graduate Student
Undergraduate Student

Racial Category (Please provide numbers)
African American/Black               Asian/Asian American/Pacific Islander
Native American                          European American/White
Latina/o                                      Arab American
International
Other (if any of the above do not apply, please fill this out).

Please indicate the number of persons attending this workshop. Please provide a breakdown by gender, if possible.

Total Participants

Males        Females

Please list three workshop dates and times in order of priority. Please note that workshops for faculty, staff, and/or graduate students take approximately two hours, while workshops for undergraduate students take approximately one hour.

1. Date: Time:
2. Date: Time:
3. Date: Time:

Location: (Please be SPECIFIC)

How open to this training do you think this audience will be?

Extremely Resistant 1 2 3 4 5 Extremely Receptive

What are your goals and/or expectations for this session?

Have there been any incidents or problems that prompt having this professional development?

Have you had a workshop like this in the past? If so, when? What did it cover or not cover?

Are there particular -ism issues that you would like to have addressed?

Are there certain nuances about your organization that we should be aware of (not necessarily to be directly addressed in the workshop)?

Does the number of participants reflect all levels of your organization?

What is the primary role and function of each participant?

Due to limited resources, we request that units receiving training prepare copies of any handouts packet. The Office of Human Relations Programs will provide the contact person with the materials in advance.