Equality and Diversity Form

All information is kept confidential, and the feedback helps us to improve our services.

Why are we asking you for this information?

Please be assured that your care and treatment will not be affected as a result of making a complaint. You will be treated fairly and equally.

To help us ensure that this is the case we ask you to complete this Equality Diversity Form. This form helps us to understand more about you so we can get our care right for you. It also allows us to monitor our complaints to ensure no particular group of individuals is being underserved by our services.

Please try to answer all of the questions, if you would rather not answer a particular question, please tick the ‘Rather not say’ box.

This data is required by all NHS organisations under the Equality Act 2010.

1. What best describes your gender?(Required)

2. Is your gender identity the same as the gender you were assigned at birth?(Required)

Yes

Rather not say

3. Which of the following options best describes how you think of yourself?(Required)

4. What age are you?(Required)

5. Are your day-to-day activities limited because of a health problem or disability (including neurological/learning/behavioural needs/disabilities) which has lasted, or is expected to last, at least 12 months?(Required)

6. What is your ethnic group?(Required)

7. Do you have a religion/faith?(Required)

8A. Have you or a family member every served in the Armed Forces?(Required)

Yes

Rather not say

8B. If yes, which of the following best describes your status / history?(Required)

9. Do you have caring responsibilities?(Required)

Yes

Rather not say

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