The sample below is not all-inclusive, but intended to demonstrate how simple the questionnaire can be, and give you a head start with drafting your own form to be sent out to vendors whose qualifications are unknown to you and not readily displayed. We encourage you to include as many of the qualifying business categories listed in the "About this forum" sticky post as your institution would like to support.

This resource does not apply if your institution already has a Supplier Diversity program and questionnaire. If it does, we urge you to share your directory of Diverse Suppliers with the PACCIN community, either in this forum space, or by email to or

This is a developing movement, and we welcome any suggestions for improving this sample questionnaire. Perhaps with your collaboration we can create a fully developed PACCIN form.

Sample Questionnaire:

Our mission is to... (your institution’s Supplier Diversity Program statement)

Organizational Information:
Name of Company / Organization: ________________
Date this form completed: ________________
Name & Title of person completing form: ________________
Year Company / Organization Founded: ______
Ownership Structure (Public, private, non-profit, employee owned): ________________
Majority Minority Owned Business: ______
Percentage minority owned (whether majority ownership or not): ______
Majority Woman Owned Business Entity: ______
Percentage woman owned (whether majority ownership or not): ______

(Note: The sample categories listed above and below can be expanded to include additional Diverse Suppliers that your program wishes to support.)

Leadership Demographics:
Leaders are defined as Owners, Partners, Senior Vice Presidents, Vice Presidents, Directors, Principals or equivalent.
Total Number of Leaders: _______
Total Number of Minority Leaders: _______ Percentage: _______
Total Number of Women Leaders: _______ Percentage: _______

Total Number of Employees: _______
Total Number of Minority Employees: _______ Percentage: _______
Total Number of Women Employees: _______ Percentage: _______

Organizational Actions:
Please advise of actions that your organization is taking to expand diversity, equity and inclusion. Please also advise of numeric goals for racial and gender diversity established by your organization. As part of this, please indicate what you hope to achieve for any increases in the racial diversity of your senior management over the next 36 months.