JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
2021 CHWA Equality, Diversity and Representation Form (Board and Staff)
Please fill in this form to help us along the road to becoming a more equal alliance.
We are committed to focusing on health and cultural equity. We are working towards ensuring our Board, staff, contractors and stakeholder groups are representative in terms of socioeconomic background and all recognised protected characteristics as defined in the Equality Act 2010 (
https://www.equalityhumanrights.com/en/equality-act/protected-characteristics
). See our roadmap for more about on how we are using this information:
https://www.culturehealthandwellbeing.org.uk/roadmap-building-more-equal-alliance
Thank you for your time.
Header Image credit: A Flag for Every One, from the Good Hope Works project at Great Ormond Street Hospital, by Joanna Brinton
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Region
We would like to understand where you are based so that we can ensure CHWA is supporting practice around the country.
Where are you based?
*
East
East Midlands
Greater London
North East
North West
South East
South West
Yorkshire and Humber
Scotland
Wales
Northern Ireland
Other:
Age
Please select your age bracket
*
16-24
25-34
35-44
45- 54
55-64
65+
Prefer not to say
Gender, Sexuality and Relationships
Your gender- please select or describe the gender you most identify with or self describe:
*
Female
Genderfluid
Male
Non- binary
Transgender
Prefer not to say
Other:
Your relationships- please choose the term that best describes your relationship status or self-describe:
*
Single
Married
In a civil partnership
Separated but still legally married/in a civil partnership
Divorced
Widowed/ surviving partner
Prefer not to say
Other:
Your sexual orientation- please choose the term you most identify with or self-describe:
*
Bisexual
Gay man
Gay woman
Lesbian
Heterosexual/ Straight
Queer
Prefer not to say
Other:
Ethnicity
Following the leadership and guidance of IncArts - #BAMEOver Terms of Reference, we are asking you to share with us how you would prefer to describe your ethnicity.
Learn more about #BAMEOver - A Statement for the UK here:
https://incarts.uk/%23bameover-the-statement
How do you describe your ethnicity? If you would prefer not to say, please state N/A.
*
Your answer
Religion and Belief
Please select from the list below or self-describe:
*
No religion
Atheist
Agnostic
Buddhist
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other:
Disability
The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment which has a substantial and long-term adverse affect on their ability to carry out normal day-to-day activities.
Do you consider yourself disabled?
*
Yes
No
Other:
If the answer is yes, which of the following best describes your disability?
A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
A mental health difficulty, such as depression, schizophrenia or anxiety disorder
A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
A social/communication impairment such as a speech and language impairment or Asperger’s syndrome or other autistic spectrum disorder
A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
Blind or have a visual impairment uncorrected by glasses
D/deaf or have a hearing impairmentOption 8
Prefer not to say
Clear selection
If the answer is yes, and you would prefer to self describe, please do so here.
Your answer
Caring Responsibilities
What are your caring responsibilities? (please tick all that apply)
*
Primary carer of a child or children under 16yrs old
Primary carer of a disabled child or children
Primary carer or assistant for a disabled adult (16 years and over)
Primary carer or assistant for an older person or people (65 years and over)
Secondary carer (another person carries out main caring role)
I have no caring responsibilities
Prefer not to say
Other:
Required
Pregnancy & Maternity
Are you pregnant, on maternity leave or returning from maternity leave?
*
Yes
No
Prefer not to say
Other:
Socio-Economic Background
Which background would you consider yourself to be from?
*
Middle Class
Upper Class
Working Class
Prefer not to say
Other:
What type of school did you attend between the ages of 11 and 16?
*
State-run or state funded school-selective on academic, faith or other grounds
State-run or state funded school- non selective
Independent or fee-paying school- bursary
Independent or fee-paying school- no bursary
Attended school outside of the UK
Don't know
Prefer not to say
Other:
If you finished school after 1980, were you eligible for Free Meals School at any point during your school years?
*
Yes
No
Not applicable
Prefer not to say
What is the highest level of qualifications achieved by either of your parent(s) or guardian (s)
*
At least one has a degree level qualification
Qualifications below degree level
No formal qualifications
Don't know
Prefer not to say
Thank you
Thank you for taking the time to complete this form; we really appreciate any information you have chosen to share with us. If you have any questions or would like to get in touch with us, please email us at
info@culturehealthandwellbeing.org.uk
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
