Health & safety risks whilst under the influence Housing Crisis Relapse Care Leaver Asylum Seeker Harm caused by visitors associates or cohabitants Any Has the client completed the self-assessment form? (NB: a self-assessment must Yes / No / NA be completed and returned to interview for accommodation referrals) Referrer Print Date Signature name Sheffield Visiting Support & Supported Housing - Referral Monitoring (protected characteristics) - Details DISC aims to promote equality and inclusion to ensure fair access to the service in line with the Equalities Act 2010. These questions are used to monitor access (as part of a yearly and ongoing review) to the service and are not used to make decisions on eligibility or allocation. DISC will not discriminate unlawfully and the below questions will help us to formally review access to the service and as such are an important part of how we protect the interest of those referred to our services. However, you do have the right to not answer any or all of the below but we would ask you then tick the box appropriate to your choice not to respond. DISC’s equality protocol is available on request. Marital Status Married/ Civil Partner Other Not Married/ Not Civil Partner (single) Client prefers not to state Cohabiting/ Domestic partnership Not known by client – Divorced/ Dissolved Civil partnership Not known by referrer (only used if client not part of referral process) – Widowed Pregnancy/ Maternity Status Pregnant Client prefers not to state In Maternity (post 26 weeks of birth) Not known by client – Not pregnant/ not in maternity Not known by referrer (only used if client not part of referral process) – Disability Status Disabled Client prefers not to state Not Disabled Not known by client – Other Not known by referrer (only used if client not part of referral process) – Ethnicity White British Mixed White and Black Caribbean – White Irish Mixed White and Black African – White Other Mixed White and Asian – Asian British - Indian Black or Black British Caribbean – Asian/ Asian British - Pakistani or Black British African – Asian/ Asian British - Bangladeshi Black or Black British Other – Asian/ Asian British - Other Other Ethnic Group Chinese/ Japanese Client prefers not to state Gypsy, Roma, Travveller Not known by client – Not by referrer (only used if client not part of referral process) – Faith / Religion Christian Other Muslim Atheist
Health & safety risks whilst under the influence Housing Crisis Relapse Care Leaver Asylum Seeker Harm caused by visitors associates or cohabitants Any Has the client completed the self-assessment form? (NB: a self-assessment must be completed and returned to interview for accommodation referrals) Yes / No / NA Referrer Signature Print name Date Sheffield Visiting Support & Supported Housing - Referral Monitoring (protected characteristics) - Details DISC aims to promote equality and inclusion to ensure fair access to the service in line with the Equalities Act 2010. These questions are used to monitor access (as part of a yearly and ongoing review) to the service and are not used to make decisions on eligibility or allocation. DISC will not discriminate unlawfully and the below questions will help us to formally review access to the service and as such are an important part of how we protect the interest of those referred to our services. However, you do have the right to not answer any or all of the below but we would ask you then tick the box appropriate to your choice not to respond. DISC’s equality protocol is available on request. Marital Status Married/ Civil Partner Not Married/ Not Civil Partner (single) Cohabiting/ Domestic partnership Divorced/ Dissolved Civil partnership Widowed Other Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Pregnancy/ Maternity Status Pregnant In Maternity (post 26 weeks of birth) Not pregnant/ not in maternity Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Disability Status Disabled Not Disabled Other Client prefers not to state Not known – by client Not known – by referrer (only used if client not part of referral process) Ethnicity White British White Irish White Other Asian British - Indian Asian/ Asian British - Pakistani Asian/ Asian British - Bangladeshi Asian/ Asian British - Other Chinese/ Japanese Gypsy, Roma, Travveller Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Black or Black British – Caribbean or Black British – African Black or Black British – Other Other Ethnic Group Client prefers not to state Not known – by client Not – by referrer (only used if client not part of referral process) Faith / Religion Christian Muslim Other Atheist
Sheffield_referral.docx