Date: Ethnic Background (Please tick below) Religion/Belief (Please tick below) Asian Bangladeshi Agnostic – Asian British Atheist – Asian Indian – Baha’i Asian Pakistani Buddhist – Asian Other Christian – Black African Hindu – Black British Humanist – Black Caribbean Jain – Black Other Jewish – Chinese Muslim Latin American Rastafarian Middle Eastern Sikh White British Zoroastrian – White Irish None – White European Other – White Other Prefer not to say – Mixed Ethnicity Prefer not to say Do you consider yourself to (Please tick below) have a disability? Yes No Prefer not to say If yes: (Please tick below) Age Group (Please tick below) Blind or Visual Impairment Under 16 Deaf or Hearing Impairment 16-17 Learning Difficulty 18-24 Mental health 25-34 Mobility 35-44 Other disability 45-54 Prefer not to say 55-64 65+ Prefer not to say Gender (Please tick below) Sexual Orientation (Please tick below) Female Bisexual Male Gay Man Other Heterosexual Prefer not to say Lesbian Other Prefer not to say Gender Identity (Please tick below) Other Categories Yes Marital Status Is your gender identity the Prefer not to say same as the gender you were No Pregnancy assigned at birth? Prefer not to say Prefer not to say
Ethnic Background (Please tick below) Religion/Belief (Please tick below) Asian – Bangladeshi Agnostic Asian – British Atheist Asian – Indian Baha’i Asian – Pakistani Buddhist Asian – Other Christian Black – African Hindu Black – British Humanist Black – Caribbean Jain Black – Other Jewish Chinese Muslim Latin American Rastafarian Middle Eastern Sikh White – British Zoroastrian White – Irish None White – European Other White – Other Prefer not to say Mixed Ethnicity Prefer not to say Do you consider yourself to have a disability? (Please tick below) Yes No Prefer not to say If yes: (Please tick below) Age Group (Please tick below) Blind or Visual Impairment Under 16 Deaf or Hearing Impairment 16-17 Learning Difficulty 18-24 Mental health 25-34 Mobility 35-44 Other disability 45-54 Prefer not to say 55-64 65+ Prefer not to say Gender (Please tick below) Sexual Orientation (Please tick below) Female Bisexual Male Gay Man Other Heterosexual Prefer not to say Lesbian Other Prefer not to say Gender Identity (Please tick below) Other Categories Is your gender identity the same as the gender you were assigned at birth? Yes No Marital Status Prefer not to say Pregnancy Prefer not to say Prefer not to say Date:
EO-Monitoring-Form-June-2018.docx