Inclusion Data Review Request Form
Submit a request to review data for inclusion, diversity, and equity considerations.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Department or Organization
*
Role or Position
Purpose of Data Review
*
Type of Data for Review
*
Please Select
Demographic Data
Survey Results
HR Records
Program Participation Data
Other
Brief Description of Data (or attach file below)
*
Upload Data File (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Which inclusion criteria should be reviewed? (Select all that apply)
*
Gender Representation
Ethnic/Racial Diversity
Disability Inclusion
Age Diversity
Socioeconomic Status
Other
Inclusion Criteria Assessment
Rows
Meets Criteria
Partially Meets
Does Not Meet
Not Applicable
Gender Representation
1
2
3
4
Ethnic/Racial Diversity
5
6
7
8
Disability Inclusion
9
10
11
12
Age Diversity
13
14
15
16
Socioeconomic Status
17
18
19
20
Please provide any additional comments or context regarding the data or inclusion review.
Review Outcome
*
Approved
Approved with Recommendations
Not Approved – Further Action Needed
Signature (Required for submission)
*
Submit Review Request
Submit Review Request
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