Are your day-to-day activities limited because of a physical or mental health condition or illness which has lasted, or is expected to last, at least 12 months? Yes, limited a lot □ Yes, limited a little No Prefer not to say □ □ □ please can you tell us which health conditions or illnesses limit your day-to-day If “Yes”, activities (Please select all that apply) Vision Ability to concentrate, learn or Stamina or breathing difficulty □ □ □ Hearing understand (learning disability / or fatigue □ Mobility difficulty) Other, please describe: □ □ Dexterity Mental □ □ Memory Social or behavioural issues Prefer not to say □ □ □ Please choose one option that best describes your Ethnic Group or Background: White English / Welsh / Scottish / Northern Irish / □ Black / African / Caribbean / Black British British African □ Irish □ Caribbean □ Gypsy or Irish Traveller □ Somali □ Other Western European □ Any other Black / African / Caribbean □ Polish □ background, please describe: Other Eastern European □ European Mixed □ Mixed/multiple ethnic groups Any other White background, please describe: □ White and Asian □ White and Black African □ Asian/Asian British White and Black Caribbean □ Indian or British Indian □ Any other mixed / multiple ethnic background, □ Pakistani or British Pakistani □ please describe: Bangladeshi or British Bangladeshi □ British Asian □ Other ethnic group Sri Lankan □ Arab □ Chinese □ Any other ethnic group, please describe: □ Any other Asian background, please describe: □ Prefer not to say □ Please choose one option that best describes your religion or belief? Baha'i Hindu Sikh □ □ □ Buddhist Jain Prefer not to say □ □ □ Christian Jewish Any other religion, please (including Church of □ □ □ England, Catholic, Protestant, and Muslim describe: □ all other Christian denominations) No religion □ Please choose your preferred language option for communicating and interpreting information: Arabic Hindi Somali □ □ □ Bengali Mandarin Chinese Urdu □ □ □ British Sign Language Panjabi Yue Chinese (Cantonese) □ □ □ English Polish Any other preferred □ □ □ Gujarati Portuguese language, please describe: □ □
Are your day-to-day activities limited because of a physical or mental health condition or illness which has lasted, or is expected to last, at least 12 months? □ Yes, limited a lot □ Yes, limited a little □ No □ Prefer not to say If “Yes”, please can you tell us which health conditions or illnesses limit your day-to-day activities (Please select all that apply) □ Vision □ Hearing □ Mobility □ Dexterity □ Memory □ Ability to concentrate, learn or understand (learning disability / difficulty) □ Mental □ Social or behavioural issues □ Stamina or breathing difficulty or fatigue □ Other, please describe: □ Prefer not to say Please choose one option that best describes your Ethnic Group or Background: White □ English / Welsh / Scottish / Northern Irish / British □ Irish □ Gypsy or Irish Traveller □ Other Western European □ Polish □ Other Eastern European □ European Mixed □ Any other White background, please describe: Asian/Asian British □ Indian or British Indian □ Pakistani or British Pakistani □ Bangladeshi or British Bangladeshi □ British Asian □ Sri Lankan □ Chinese □ Any other Asian background, please describe: Black / African / Caribbean / Black British □ African □ Caribbean □ Somali □ Any other Black / African / Caribbean background, please describe: Mixed/multiple ethnic groups □ White and Asian □ White and Black African □ White and Black Caribbean □ Any other mixed / multiple ethnic background, please describe: Other ethnic group □ Arab □ Any other ethnic group, please describe: □ Prefer not to say Please choose one option that best describes your religion or belief? □ Baha'i □ Buddhist □ Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) □ Hindu □ Jain □ Jewish □ Muslim □ No religion □ Sikh □ Prefer not to say □ Any other religion, please describe: Please choose your preferred language option for communicating and interpreting information: □ Arabic □ Bengali □ British Sign Language □ English □ Gujarati □ Hindi □ Mandarin Chinese □ Panjabi □ Polish □ Portuguese □ Somali □ Urdu □ Yue Chinese (Cantonese) □ Any other preferred language, please describe:
EqualityMonitoringFormFeb2016Font12.docx