EQUALITY & DIVERSITY MONITORING

The following information is recorded for monitoring the effectiveness of our compliance with our various contracts and the Equality Act 2010. The information you chose to disclose will not in any way be used as part of your acceptance on to a programme, service or employment vacancy. Please tick any of the following boxes that apply to you

Service/Contract (Please specify)

Customer Staff Applicant Other: (Please specify) Disability and/or Long Term Health Condition Communications Moderate Hearing Loss (One Ear) Asthma Without Speech Mild Hearing Loss (Both) Allergies, Allergic Reactions Limited Speech Mild Hearing Loss (One Ear) Epilepsy Impaired Speech Tinnitus Thyroid Problem Stutter Other Hearing Blood Pressure Stammer Learning Difficulty Stroke Other Communications Dyslexia Scoliosis Dexterity Dyslexia - Meares Irlen Syndrome Lupus Carpal Tunnel Syndrome (RSI) Dyscalculia Hepatitis C Rheumatoid Arthritis ADHD Marfan Syndrome Osteoarthritis Autistic Spectrum Disorder Other Long Term Health Condition Fibromyalgia Asperger Mobility Osteoporosis Acquired Brain Injury Paraplegic Dyspraxia Other Learning Difficulty Stroke Other Dexterity Downs Syndrome Tetraplegic Ataxia Fragile X Syndrome Quadriplegic Emotional Global Development Delay Hemiplegic Learning Disability (Known to Social Depression Amputee Lower Limb(s) Services) Learning Disability (Not known to Clinical Depression Multiple Sclerosis (MS) Social Services) Bipolar Disorder Williams syndrome Motor neurone disease Intrusive Thoughts/Feelings Microcephaly Spina Bifida Schizophrenia Long Term Health Condition Spinal Degeneration Stress Cardiac Disease Cerebral Palsy Gulf War Syndrome Diabetes Back Problems Post-Traumatic Stress Disorder COPD Other Mobility Other Emotional Lung Disease Social Gender Re-assignment Kidney Disease Tourette's Syndrome Hearing Liver Disease Panic Attacks Severe Hearing Loss (Both) Crohn’s Disease Anxiety Severe Hearing Loss (One Ear) Cancer Social Anxiety Disorder Moderate Hearing Loss (Both) HIV Positive Agoraphobia Disability and/or Long Term Health Condition (continued) Form Equality & Diversity Owner Director of Finance & Corporate Services Version 1.2 Signature Effective Date 06/02/17 Page Page 1 of 2 Social Deprivation Area Registered Partially Sighted (One Claustrophobia Eye) Obsessive Compulsive Disorder Armed Forces Leaver Tunnel Vision (OCD) Other Social Other Barrier Unclassified Retina Pigmentosa Other Barriers Stamina Peripheral Vision Issues Alcohol Addiction ME Other Vision Other Disability / Long Term Health Drug Addiction Chronic Fatigue Syndrome (CFS) Condition Substance Abuse Other Stamina Please state: Homelessness Myasthenia gravis Recent Offender Vision Single Parent Registered Blind (One Eye) Care Leaver Registered Partially Sighted (Both)

Ethnicity White Pakistani Other Black Background British Bangladeshi Mixed Heritage Irish Chinese White and Black Caribbean European Other Asian Background White and Black African Other White Background Black White and Asian Asian Black British Other Mixed Background Asian British Caribbean Indian African Prefer not to say

Religion or Belief No Religion or Belief Buddhist Christian Hindu Jewish Muslim Sikh Prefer not to say Other:

Gender Sexual Orientation Male Female Heterosexual Gay Transgender Prefer not to say Bisexual Prefer not to say

Caring Responsibilities Primary Carer of a Child/Children Primary Carer of Disabled None (under 18) Child/Children (Under 18) Primary Carer of Disabled Adult Secondary Carer (another person Primary Carer of Older Person (18+ years old) carries out the main caring role) Prefer not to say

Age 16-24 25-34 35-44 45-54 55-64 65+ Prefer not to say

Form Equality & Diversity Owner Director of Finance & Corporate Services Version 1.2 Signature Effective Date 06/02/17 Page Page 2 of 2