Equal Opportunities Monitoring Form s3

Equal Opportunities Monitoring Form Volunteer You are not required to complete this anonymous form, but we would be grateful if you would take the time to do so. Any information provided will only be used to collate statistics which will which will help Circles UK and member Projects in their wider diversity developments. 1. Are you: Female Male

1. How would you describe your sexuality? Bi-sexual Gay Heterosexual Lesbian Prefer not to say

Asian or Asian British Mixed Indian White & Black Caribbean Pakistani White & Black African Bangladeshi White & Asian Any other Asian Any other mixed heritage Background Under the Disability Discrimination Act (DDA) a disability is defined as physical, sensory or mental impairment which has, or had, a substantial and long-term effect on a person’s ability to carry out normal day to day activities. 5. Do you consider yourself to have a disability? Yes No Specific learning disability Physical impairment or mobility (e.g. dyslexia) issues General learning disability Deaf or serious hearing impairment (e.g. Down’s Syndrome) Cognitive impairment Blind or serious sight impairment (e.g. autistic spectrum disorder) Long-standing health condition Other (please state) (e.g. diabetes) ______Mental health condition Prefer not to say

2. Are you employed: Full time Part time Retired Student Unemployed