QUESTIONNAIRE - DISABILITY EQUALITY SCHEME
Name: …………………………………………………..(Please print)
Staff/Student/Parent or Guardian/Governor/Community User (Delete as necessary)
1. Do you consider yourself to be disabled as set out under the Disability Discrimination Act? YES / NO2. Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘Other’ and specify the type of impairment.
DISABILITY / YES-Please specifyPhysical impairment, such as difficulty using your arms or mobility issues
Sensory impairment, such as being blind / having a serious visual impairment or being deaf / having a serious hearing impairment
Mental health condition, such as depression
Learning disability / difficulty, (such as dyslexia) or cognitive impairment (such as autistic spectrum disorder)
Long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
Other (please specify)
3. It can help us to ensure effective involvement of everyone if we can identify anything that poses a barrier to your full participation.
What are the biggest barriers for you in doing what you want to do in this organisation? Please tick any that apply and specify.
BARRIER / PLEASE TICK AND SPECIFYAccess to buildings
Written information or communication
Verbal or audible information / communication
People’s attitudes to you because of your impairment, medical condition or disability
Lack of reasonable adjustments
Policies or procedures such as the fire evacuation procedure
Other barriers (please specify)
4. Please tick the adjacent box if you do not wish this information to be shared with other professionals who might need to know in order for any reasonable adjustments to be made.
5. Would you be interested in joining a Working Party that will help us develop our Disability Equality Scheme? YES / NO
6. Any other comments?
Please sign as appropriate below. Student questionnaires must be signed by both student and parent/guardian.
Staff/Governor/Community User(delete as necessary)signature: ……………………………………….
Parent/Guardiansignature:…………………………………… (For parents/guardians with disability, please indicate names and Tutor Groups of all of your children at Hodgson)……………………………………………………
…………………………………………………………………………………………………………………………………………………………………….
Student signature (student with disability only): ……………………… Tutor Group: …………….
Date: ……………………..
Confidentiality and anonymity of reported information is guaranteed. Participants should be assured that personal information will not be disclosed to others without their permission. Participation is entirely voluntary. Please return to Mrs R Townley, Assistant Headteacher or Mr M Pickles, School Business Manager at HodgsonSchool in an envelope marked ‘private and confidential’