Equality Monitoring Questionnaire 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.

1.What is your case reference number?(Required.)

2.What is your age?(Required.)

3.How would you describe your national identity?(Required.)

4.Which term best describes your sex?(Required.)

Male

Female

Prefer not to say

I prefer to use my own term

Trans is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth.

5.Do you identify as trans?(Required.)

Ethnic origin categories are not about nationality, place of birth or citizenship. They are about the group to which you as an individual perceive you belong.

6.How would you describe your ethnicity?(Required.)

White

Asian, Asian Welsh or Asian British

Mixed or multiple ethnic groups

Black, Black Welsh, Black British, Caribbean or African

Other ethnic group or prefer not to say

Ethnicity

Other (please specify)

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.

7.Do you define yourself as disabled?(Required.)

8.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?(Required.)

9.If yes, please indicate which of the following may be relevant to you:

Sight loss

Hearing loss

Mobility impairment e.g. difficulty walking short distances or climbing stairs

Dyslexia or another learning difficulty

Learning disability

Mental health condition e.g. schizophrenia, depression, anxiety

Other e.g. cancer

Prefer not to say

10.What is your religion or belief (including lack of belief)?(Required.)

11.What is your main language?(Required.)

12.Can you understand, speak, read or write Welsh? Please select all relevant answers.(Required.)

13.Are you married or in a civil partnership?(Required.)

14.Which of the following best describes your sexual orientation?(Required.)

We want to make sure that as we work we help to reduce inequalities associated with socio-economic disadvantage. Some people may be vulnerable because of their health, income, housing conditions or other factors. We ask the questions below to help us understand how these different factors may influence who uses our service.