Equality Monitoring Form (strictly confidential) This form can be provided in large print, Braille formats, and different languages on request. Additionally, an interpreting service is available to those who require it. Please refer to the contact details given below. For any questions or feedback regarding this form please contact the Equality and Human Rights Team either by phone: 0116 295 7680 or e-mail: Leicestershire Partnership NHS Trust recognises and actively promotes the benefits of diversity and is committed to treating everyone with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. To ensure that our services are designed for the population we serve, we would like you to complete the short monitoring section below. The information provided will only be used for the purpose described above and will not be passed on to any third parties. Data Protection Statement - All information will be kept strictly confidential and in accordance with the Data Protection Act 1998 and associated protocols. Please tick () the relevant box following each question. What is your Postcode? The first part of your postcode, this may be three or four letters/numbers (for example, LE6 or LE11). This information will help us to understand where services may need to be directed (we will not be able to identify your address from this information). First part of post code not to say □ Prefer What is your Date of Birth? M M Y Y Y Y not to say □ Prefer What is your Gender / Sex? Male Female Prefer not to say □ □ □ Do you live and work, or intend to live and work, in a gender other than that assigned at birth? Yes No Prefer not to say □ □ □ Please choose one option that best describes how you think of yourself: Heterosexual / Straight Gay Other □ □ □ Bisexual Lesbian Prefer not to say □ □ □ Please choose one option that best describes your relationship status: Married / Civil partnership □ Divorced / Dissolved civil Widowed / Surviving civil Single □ □ □ partnership partner Other □ Separated, but still legally Living with partner Prefer not to say □ □ □ married or in a civil partnership In a relationship □ Are you pregnant or on maternity leave? Yes No Prefer not to say □ □ □
Equality Monitoring Form (strictly confidential) This form can be provided in large print, Braille formats, and different languages on request. Additionally, an interpreting service is available to those who require it. Please refer to the contact details given below. For any questions or feedback regarding this form please contact the Equality and Human Rights Team either by phone: 0116 295 7680 or e-mail: Leicestershire Partnership NHS Trust recognises and actively promotes the benefits of diversity and is committed to treating everyone with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. To ensure that our services are designed for the population we serve, we would like you to complete the short monitoring section below. The information provided will only be used for the purpose described above and will not be passed on to any third parties. Data Protection Statement - All information will be kept strictly confidential and in accordance with the Data Protection Act 1998 and associated protocols. Please tick () the relevant box following each question. What is your Postcode? The first part of your postcode, this may be three or four letters/numbers (for example, LE6 or LE11). This information will help us to understand where services may need to be directed (we will not be able to identify your address from this information). First part of post code □ Prefer not to say What is your Date of Birth? M M Y Y Y Y □ Prefer not to say What is your Gender / Sex? □ Male □ Female □ Prefer not to say Do you live and work, or intend to live and work, in a gender other than that assigned at birth? □ Yes □ No □ Prefer not to say Please choose one option that best describes how you think of yourself: □ Heterosexual / Straight □ Bisexual □ Gay □ Lesbian □ Other □ Prefer not to say Please choose one option that best describes your relationship status: □ Married / Civil partnership □ Divorced / Dissolved civil partnership □ Separated, but still legally married or in a civil partnership □ Widowed / Surviving civil partner □ Living with partner □ In a relationship □ Single □ Other □ Prefer not to say Are you pregnant or on maternity leave? □ Yes □ No □ Prefer not to say
EqualityMonitoringFormSeptember2013.docx