Thank you for considering participating in our equality monitoring. We would be grateful if you would answer the following questions, which are entirely optional. If you are not comfortable answering any particular question, please tick the box 'prefer not to say'.

The questions below relate to the person who has suffered the problem. If you have complained on behalf of someone else, we'd be grateful if you could assist them in completing this survey. 
When you complete this form, we ask you for your case reference number.  We do this, because it allows us to better analyse the accessibility of our service - for example based on the subject or type of complaints.

Please be assured that your response will not be seen at any point by any member of staff responsible for assessing or investigating your complaint.  Only the staff who are undertaking the analysis will see it. 

You can find this reference number in all correspondence from us about your case.

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* 1. What is your case reference number?

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* 2. What was your age at your last birthday?

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* 3. How would you describe your nationality?

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* 4. What is your gender?

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* 5. What is your ethnic group?

  White Asian or Asian British  Mixed or multiple ethnic groups Black, African, Caribbean or Black British Other ethnic group or prefer not to say
Ethnicity

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* 6. What is your household's main language?

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* 7. What is your current working status?

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* 8. Which of the following qualifications do you have?

The Equality Act 2010 defines a disabled person according to the medical model, as someone who has a physical or mental impairment that has a ‘substantial’ and ‘long-term’ adverse effect on their ability to perform normal day-to-day activities (like eating, walking and going shopping).

'Substantial' in this context means 'more than minor or trivial', whilst 'long-term' means that the effect of the impairment has lasted or is likely to last for at least twelve months. This definition also covers people who have been diagnosed with HIV, cancer or multiple sclerosis.

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* 9. Do you consider yourself to be disabled?

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* 10. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last at least 12 months?

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* 11. What is your religion?

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* 12. Which of the following best describes your marital status?

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* 13. Is the gender you identify with the same as the sex you were assigned at birth?

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* 14. Which of the following options best describes how you think of yourself?

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