Equality Monitoring Form - NHS England

1 Equality Monitoring FormWhat is your sex?FemaleMalePrefer not to sayWhen were you born?DayMonthYea rWhat is your sexual orientation?Bisexual (both sexes)Lesbian womanGay manHeterosexual (other sex)Prefer not to sayAccessible Information Standard Review: Diversity Monitoring QuestionsWe are asking these questions because we want to make sure that we have asked lots of different people for their views. You do not have to answer these questions if you do not want you consider yourself to have any religion?BuddhismIslamChristianityNo ReligionJudaismHinduismPrefer notto saySikhism Other (Please say):What is your ethnic background?Asian, or Asian BritishBangladeshiPakistaniChineseOtherB lack, or Black BritishAfricanOtherCaribbeanAtheismIndia nMixedAsian and WhiteBlack african and WhiteBlack Caribbean and WhiteOtherWhiteWelsh / English / Scottish /Northern Irish / BritishOtherOtherAny OtherIf any other ethnic background, please state here:Prefer not to sayIrishGypsy or Irish TravellerArabDo you consider yourself to have a disability?

2 Please tell us the type of disability you haveDo you look after, or give any help or support to a family member, friend or neighbour because of long term physical disability, mental ill-health or problems related to old age?YesNoPrefer not to sayYesNoPrefer not to sayThank you for completing these diversity Monitoring questions. Please return your completed survey by email post the survey to Accessible Information StandardNHS England7E56 Quarry HouseQuarry HillLeedsLS2 7UE. Please return your completed survey before the deadline of 10th March 2017.