2 Gender Female Male Do not wish to disclose 3 Age 16 20 21 25 26 30 – – – 31 35 36 40 41 45 – – – 46 50 51 55 56 60 – – – 61 65 66 70 71 75 – – – I would rather not answer 4 I describe my ethnic origin as… or Asian British Mixed Other Ethnic Groups Bangladeshi and Asian Chinese Indian White and Black African Any Ethnic Group Pakistani and Black Caribbean Any other Asian background Any other mixed background Black or Black British White African British I do not wish to disclose my ethnic origin Caribbean Irish Any Black background Any other White background 5 Please select the option which best describes your sexual orientation Gay woman/Lesbian Other please specify below – Gay man Bisexual Heterosexual I do not wish to disclose my sexuality 6 Please indicate your religion or belief please specify below – Atheism Islam Buddhism Jainism Christianity Judaism Hinduism Sikhism I have no religion/belief I do not wish to disclose my religion/belief 7 Do you consider yourself to have a Yes disability? No
2 Gender Female Male Do not wish to disclose 3 Age 16 – 20 21 – 25 26 – 30 31 – 35 36 – 40 41 – 45 46 – 50 51 – 55 56 – 60 61 – 65 66 – 70 71 – 75 I would rather not answer 4 I describe my ethnic origin as… or Asian British Bangladeshi Indian Pakistani Any other Asian background Mixed and Asian White and Black African and Black Caribbean Any other mixed background Other Ethnic Groups Chinese Any Ethnic Group Black or Black British African Caribbean Any Black background White British Irish Any other White background I do not wish to disclose my ethnic origin 5 Please select the option which best describes your sexual orientation Gay woman/Lesbian Gay man Bisexual Heterosexual Other – please specify below I do not wish to disclose my sexuality 6 Please indicate your religion or belief Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism – please specify below I have no religion/belief I do not wish to disclose my religion/belief 7 Do you consider yourself to have a disability? Yes No
Improving-care-Application-form-w-equal-opps.docx