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Equalities monitoring form
This is confidential and not personally attributable. It will be used for monitoring and reporting purposes only, and stored anonymously in accordance with the Data Protection Act.
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Which of the following describes how you think of yourself?
Female
Male
Prefer not to say
In another way
Other
How old are you?
18-24
25-30
31-34
35-39
40-49
50-59
60-69
70+
Other:
What is your sexual orientation?
Bisexual
Gay/Lesbian
Heterosexual/Straight
Prefer to self-describe
Prefer not to say
Other
Other:
Do you consider yourself to have a disability? The Equality Act 2010 defines disability as 'a physical or mental impairment with long term substantial adverse effects on a person's ability to perform day-to-day activities.
Yes
No
Prefer not to say
Other:
What is your ethnic group?
English/Welsh/Scottish/Northern Irish/British
Irish
Gypsy or Irish Traveller
White and Black Caribbean
White and Black African
White and Asian
White other
Any other Mixed/Multiple ethnic background, please describe:
Indian
Pakistani
Bangladeshi
Chinese
African
Caribbean
Any other Black/African/Caribbean background, please describe:
Arab
Other
Other:
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