South East Coast Ambulance Service (SECAmb) - Diversity Monitoring Questionnaire

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South East Coast Ambulance Service (SECAmb) - Diversity Monitoring Questionnaire - Non-Executive Director

First Name *

Surname *

Age *

29 or under

30 to 39

40 to 49

50 to 59

60 to 64

65 and over

Prefer not to say

Ethnic Background - which of the following do you feel you most identify with? (please tick one only)

Bangladeshi

Indian

Pakistani

Any other Asian background

Asian

Clear selection

African

Caribbean

Any other Black background

Black

Clear selection

Any Chinese background

Chinese

Clear selection

Any White background

White

Clear selection

Asian & White

Black African & White

Black Caribbean & White

Any other mixed ethnic background

Mixed Ethnic background

Clear selection

Any other ethnic background

Clear selection

Prefer not to say

Clear selection

Nationality - which of the following do you feel you most identify with? *

British or Mixed British

Any other nationality

Prefer not to say

Disability (The Equality Act 2010 defines a person with a disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities) *

Yes

Prefer not to say

Dependants (children under 16, children with a disability under 18, adults that are in need of care) *

Yes

Prefer not to say

Sexual Orientation *

Bisexual

Gay Man

Gay Woman / Lesbian

Heterosexual / Straight

Other

Prefer not to say

Religion and Belief - below is a list of religions and beliefs that are the most commonly found in Britain. They are listed in alphabetical order and not intended to signify rank in terms of importance. Furthermore we acknowledge that the list is not exhaustive and if your religion is not specifically listed please insert your religion in the space provided.Which belief, non-belief or religion do you feel you most identify with? *

Agnosticism

Atheism

Buddhism

Christianity

Hinduism

Islam

Judaism

Sikhism

Other Religion or Belief

Prefer not to say

Gender Identity *

Man (including trans man)

Woman (including trans woman)

Other Gender Identity (e.g. androgyne person)

Prefer not to say

Is your gender identity the same as the gender you were assigned at birth? *

Yes

Prefer not to say

Submit

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