The following information is recorded for monitoring the effectiveness of our compliance with our various contracts and the Equality Act 2010. The information you chose to disclose will not in any way be used as part of your acceptance on to a programme, service or employment vacancy. Please tick any of the following boxes that apply to you
Service/Contract (Please specify)Customer / Staff / Applicant / Other: (Please specify)
Disability and/or Long Term Health Condition
Communications / Moderate Hearing Loss (One Ear) / Asthma
Without Speech / Mild Hearing Loss (Both) / Allergies, Allergic Reactions
Limited Speech / Mild Hearing Loss (One Ear) / Epilepsy
Impaired Speech / Tinnitus / Thyroid Problem
Stutter / Other Hearing / Blood Pressure
Stammer / Learning Difficulty / Stroke
Other Communications / Dyslexia / Scoliosis
Dexterity / Dyslexia - Meares Irlen Syndrome / Lupus
Carpal Tunnel Syndrome (RSI) / Dyscalculia / Hepatitis C
Rheumatoid Arthritis / ADHD / Marfan Syndrome
Osteoarthritis / Autistic Spectrum Disorder / Other Long Term Health Condition
Fibromyalgia / Asperger / Mobility
Osteoporosis / Acquired Brain Injury / Paraplegic
Dyspraxia / Other Learning Difficulty / Stroke
Other Dexterity / Downs Syndrome / Tetraplegic
Ataxia / Fragile X Syndrome / Quadriplegic
Emotional / Global Development Delay / Hemiplegic
Depression / Learning Disability (Known to Social Services) / Amputee Lower Limb(s)
Clinical Depression / Learning Disability (Not known to Social Services) / Multiple Sclerosis (MS)
Bipolar Disorder / Williams syndrome / Motor neurone disease
Intrusive Thoughts/Feelings / Microcephaly / Spina Bifida
Schizophrenia / Long Term Health Condition / Spinal Degeneration
Stress / Cardiac Disease / Cerebral Palsy
Gulf War Syndrome / Diabetes / Back Problems
Post-Traumatic Stress Disorder / COPD / Other Mobility
Other Emotional / Lung Disease / Social
Gender Re-assignment / Kidney Disease / Tourette's Syndrome
Hearing / Liver Disease / Panic Attacks
Severe Hearing Loss (Both) / Crohn’s Disease / Anxiety
Severe Hearing Loss (One Ear) / Cancer / Social Anxiety Disorder
Moderate Hearing Loss (Both) / HIV Positive / Agoraphobia
Disability and/or Long Term Health Condition (continued)
Claustrophobia / Social Deprivation Area / Registered Partially Sighted (One Eye)
Obsessive Compulsive Disorder (OCD) / Armed Forces Leaver / Tunnel Vision
Other Social / Other Barrier Unclassified / Retina Pigmentosa
Other Barriers / Stamina / Peripheral Vision Issues
Alcohol Addiction / ME / Other Vision
Drug Addiction / Chronic Fatigue Syndrome (CFS) / Other Disability / Long Term Health Condition
Substance Abuse / Other Stamina / Please state:
Homelessness / Myasthenia gravis
Recent Offender / Vision
Single Parent / Registered Blind (One Eye)
Care Leaver / Registered Partially Sighted (Both)
Ethnicity
White / Pakistani / Other Black Background
British / Bangladeshi / Mixed Heritage
Irish / Chinese / White and Black Caribbean
European / Other Asian Background / White and Black African
Other White Background / Black / White and Asian
Asian / Black British / Other Mixed Background
Asian British / Caribbean
Indian / African / Prefer not to say
Religion or Belief
No Religion or Belief / Buddhist / Christian
Hindu / Jewish / Muslim
Sikh / Prefer not to say / Other:
Gender / Sexual Orientation
Male / Female / Heterosexual / Gay
Transgender / Prefer not to say / Bisexual / Prefer not to say
Caring Responsibilities
None / Primary Carer of a Child/Children (under 18) / Primary Carer of Disabled Child/Children (Under 18)
Primary Carer of Disabled Adult (18+ years old) / Primary Carer of Older Person / Secondary Carer (another person carries out the main caring role)
Prefer not to say
Age
16-24 / 25-34 / 35-44 / 45-54 / 55-64 / 65+ / Prefer not to say
Form / Equality & Diversity / Owner / Director of Finance & Corporate Services
Version / 1.2 / Signature /
Effective Date / 06/02/17 / Page / Page 1 of 2