Equality and Diversity Monitoring Form

The information contained in this questionnaire will be treated as confidential and processed
in line with the Data Protection Act 2018 and the General Data Protection Regulation.

AGE

What is your age? Please mark ‘X’ in one box only

☐ 16-24
☐ 25-34
☐x 35-44
☐ 45-54
☐ 55-64
☐ 64+
☐ Prefer not to say

DISABILITY

A disabled person is defined under the Equality Act 2010 as someone with a ‘physical or
mental impairment which has a substantial and long term adverse effect on that
person’s ability to carry out normal day-to-day activities.’

Do you consider yourself to be disabled under the Equality Act 2010? Please mark ‘X’ in the
appropriate box.

☐ Yes
☐x No
☐ Don’t know
☐ Prefer not to say

If YES, please answer the following question; otherwise proceed to the next section. Please
indicate by marking ‘X’ in the appropriate box, mark all that apply.

☐ Hearing impairment
☐ Visual impairment
☐ Speech impairment
☐ Mobility impairment
☐ Physical coordination difficulties
☐ Reduced physical capacity
☐ Severe disfigurement
☐ Learning difficulties (e.g. dyslexic)
☐ Mental health issues
☐ Progress conditions
☐ If other, please specify
ETHNIC ORIGIN

Which groups do you most identify with? Please answer both questions, putting one ‘X’ under
Regional background, and one ‘X’ under Ethnic background.

Regional background (Select one option)

☐ British or Mixed White British

☐ English
☐ Irish
☐ Scottish
☐ Welsh
☐ Any other, please specify:

Latin

Ethnic background (Select one option)

ASIAN MIXED ETHNIC BACKGROUND

☐ Bangladeshi ☐ Asian and White

☐ Indian ☐ Black African and White
☐ Pakistani ☐ Any other mixed ethnic background,
☐ Any other Asian background, please specify:
please specify:

WHITE
BLACK
☐x Any White background, please specify:
☐ African
☐ Caribbean Latin
☐ Any other Black background,
ANY OTHER ETHNIC BACKGROUND
please specify:
☐ Any other ethnic background, please
specify:
CHINESE

☐ Any Chinese background, please

specify:
GENDER

☐ Female
☐x Male
☐ Prefer not to say
☐ Prefer to self-describe:

GENDER IDENTITY
Is your gender identity the same as the sex you were assigned at birth?

☐x Yes
☐ No
☐ Prefer not to say

WHAT IS YOUR SEXUAL ORIENTATION?

☐x Bi-sexual
☐ Gay woman/lesbian
☐ Gay man
☐ Heterosexual/straight
☐ Prefer not to say
☐ Prefer to self-describe:

RELIGION OR BELIEF

☐ Agnostic ☐ Pagan
☐x Atheist ☐ Sikh
☐ Rastafarian
☐ Bah’ai
☐ Scientologist
☐ Buddhist
☐ Shinto
☐ Christian - Catholic ☐ Zoroastrian
☐ Christian - Protestant ☐ No religion or belief
☐ Christian - Other ☐ Prefer not to say
☐ Hindu ☐ Any other religion or belief.
☐ Humanism Please specify below, if you wish:
☐ Jain
☐ Jewish
☐ Muslim

Thank you for completing this Equality and Diversity Monitoring Form.