☐ Caribbean ☐ Any Black / African / Caribbean background, please describe ______________________ Other ethnic group ☐ Arab ☐ Any other ethnic group, please describe ____________________________________________ ☐ I prefer not to say 3. Age What was your age group at your last birthday? ☐ 16-24 ☐ 25-34 ☐ 35-44 ☐ 45-54 ☐ 55-64 ☐ 65-74 ☐ 75-84 ☐ 85 or over ☐ I prefer not to say 4. Sexual Orientation What is your sexual orientation? ☐ Bisexual ☐ Gay or lesbian ☐ Heterosexual ☐ Other ☐ I prefer not to say 5. Religion or belief What is your religion or belief? ☐ Buddhist ☐ Christian ☐ Hindu ☐ Jewish ☐ Muslim ☐ Sikh ☐ ☐ No Religion or Atheist ☐ I prefer not to say 6. Where is your principle place of residence? Which region does your principal residence fall within? ☐ North East ☐ North West ☐ Yorkshire and Humberside ☐ East Midlands ☐ West Midlands
☐ Caribbean ☐ Any Black / African / Caribbean background, please describe ______________________ Other ethnic group ☐ Arab ☐ Any other ethnic group, please describe ____________________________________________ ☐ I prefer not to say 3. Age What was your age group at your last birthday? ☐ 16-24 ☐ 25-34 ☐ 35-44 ☐ 45-54 ☐ 55-64 ☐ 65-74 ☐ 75-84 ☐ 85 or over ☐ I prefer not to say 4. Sexual Orientation What is your sexual orientation? ☐ Bisexual ☐ Gay or lesbian ☐ Heterosexual ☐ Other ☐ I prefer not to say 5. Religion or belief What is your religion or belief? ☐ Buddhist ☐ Christian ☐ Hindu ☐ Jewish ☐ Muslim ☐ Sikh ☐ ☐ No Religion or Atheist ☐ I prefer not to say 6. Where is your principle place of residence? Which region does your principal residence fall within? ☐ North East ☐ North West ☐ Yorkshire and Humberside ☐ East Midlands ☐ West Midlands
UKSA-Steering-Board-Chair-Diversity-Form.docx