5. Do you consider yourself to be 7. Are you pregnant? disabled? Yes No Yes No Prefer not to say Prefer not to say Type of impairment: 8. Have you given birth in the last 6 months? Please tick all that Yes No Physical or mobility impairment Prefer not to say (such as using a wheelchair to get around and / or difficulty using their arms) 9. Please select the option that best Sensory impairment represents your sexual orientation? (such as being blind / having a serious Bisexual (both sexes) visual impairment or being deaf / having a serious hearing impairment) Gay (same sex) Heterosexual/straight (opposite sex) Mental health condition Lesbian (same sex) (such as depression or schizophrenia) Learning disability Prefer not to say (such as Downs syndrome or dyslexia) or cognitive impairment (such as autism or head-injury) 10. Are you transgender? Is your gender identity different to the gender Long term condition you were assigned at (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) Yes No Prefer not to say Prefer not to say 6. Are you a carer? Do you look after, or give any help or support to a family member, friend or neighbour because of a long term physical disability, mental ill-health or problems related to age? Yes No Prefer not to say Thank you for completing this form
5. Do you consider yourself to be disabled? Yes No Prefer not to say Type of impairment: Please tick all that Physical or mobility impairment (such as using a wheelchair to get around and / or difficulty using their arms) Sensory impairment (such as being blind / having a serious visual impairment or being deaf / having a serious hearing impairment) Mental health condition (such as depression or schizophrenia) Learning disability (such as Downs syndrome or dyslexia) or cognitive impairment (such as autism or head-injury) Long term condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) Prefer not to say 6. Are you a carer? Do you look after, or give any help or support to a family member, friend or neighbour because of a long term physical disability, mental ill-health or problems related to age? Yes No Prefer not to say 7. Are you pregnant? Yes No Prefer not to say 8. Have you given birth in the last 6 months? Yes No Prefer not to say 9. Please select the option that best represents your sexual orientation? Bisexual (both sexes) Gay (same sex) Heterosexual/straight (opposite sex) Lesbian (same sex) Prefer not to say 10. Are you transgender? Is your gender identity different to the gender you were assigned at Yes No Prefer not to say Thank you for completing this form
NK-GH-IFR-Application-Form.docx