Equality and Diversity Monitoring Form

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* 1. What is your gender?

Male

Female

Non-binary

Transgender

Prefer not to say

Other (please specify)

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* 2. What is your age?

16-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65 or over

Prefer not to say

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* 3. What is your nationality?

Welsh

British or Mixed British

English

Scotish

Northern Irish

Irish

Any white background

Chinese

Asian (other)

White and Black Caribbean

White and Black African

White and Asian

Mixed / Multiple Ethnic Groups (Other)

African

Caribbean

Black (0ther)

Indian

Pakistani

Bangladeshi

Arab

Gypsy or Irish Traveller

Prefer not to say

Any other (please specify)

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* 4. Do you have any long-standing physical or mental health condition, illness, impairment or disability? (i.e. has lasted or is expected to last at least 12 months and adverse effect on your ability to carry out normal day-to-day activities.)

Yes

Prefer not to say

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* 5. Can you understand, speak, read and / or write Welsh?
Please rate your level of fluency (1 least fluent - 4 most fluent)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. Can you understand, speak, read and / or write English?
Please rate your level of fluency (1 least fluent - 4 most fluent)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Please state any other languages you can understand, speak, read and / or write

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* 8. Are you?

In full time employment

In part-time employment

Self-employed

Not in employment

Prefer not to say

Other

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* 9. If not in employment, are you?

Studying

Retired

A stay at home parent

Unable to work due to and illness or disability

Receiving one or more Benefits or Allowances (including Universal Credit, Carers Allowance, PIP, University or College Hardship Fund but excluding non means tested Allowances)

No applicable

Prefer not to say

Other (please specify)

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* 10. Would you say your annual household income is: (including benefits/allowances)

Higher than average

Around average

Lower than average

Not Applicable

Prefer not to say

Equality and Diversity Monitoring Form

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* 1. What is your gender?

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* 2. What is your age?

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* 3. What is your nationality?

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* 4. Do you have any long-standing physical or mental health condition, illness, impairment or disability? (i.e. has lasted or is expected to last at least 12 months and adverse effect on your ability to carry out normal day-to-day activities.)

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* 5. Can you understand, speak, read and / or write Welsh?
Please rate your level of fluency (1 least fluent - 4 most fluent)

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* 6. Can you understand, speak, read and / or write English?
Please rate your level of fluency (1 least fluent - 4 most fluent)

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* 7. Please state any other languages you can understand, speak, read and / or write

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* 8. Are you?

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* 9. If not in employment, are you?

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* 10. Would you say your annual household income is: (including benefits/allowances)

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* 11. What is your postcode?

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* 12. Where did you hear about this opportunity?

Equality and Diversity Monitoring Form

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* 1. What is your gender?

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* 2. What is your age?

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* 3. What is your nationality?

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* 4. Do you have any long-standing physical or mental health condition, illness, impairment or disability? (i.e. has lasted or is expected to last at least 12 months and adverse effect on your ability to carry out normal day-to-day activities.)

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* 5. Can you understand, speak, read and / or write Welsh?Please rate your level of fluency (1 least fluent - 4 most fluent)

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* 6. Can you understand, speak, read and / or write English?Please rate your level of fluency (1 least fluent - 4 most fluent)

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* 7. Please state any other languages you can understand, speak, read and / or write

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* 8. Are you?

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* 9. If not in employment, are you?

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* 10. Would you say your annual household income is: (including benefits/allowances)

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* 11. What is your postcode?

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* 12. Where did you hear about this opportunity?

* 5. Can you understand, speak, read and / or write Welsh?
Please rate your level of fluency (1 least fluent - 4 most fluent)

* 6. Can you understand, speak, read and / or write English?
Please rate your level of fluency (1 least fluent - 4 most fluent)