13. What is your age? Up to 14 15-17 18-19 20-29 30-39 40-49 50-59 60-69 Prefer not to 70-79 80 or over say 14. What is your ethnic origin? Asian Asian Asian (Indian) Asian (Pakistan) (Bangladeshi) (Chinese) Asian (Other) Black (African) Black (Caribbean) Black (Other) Mixed (White Mixed (White (White & Black (Other) & Asian) & Black Asian) Carib) White White (Gypsy/Irish Other (Eng/Wels/ White (Irish) Traveller) Scot/NI/Brit) (Other) 15. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? Yes, limited a Yes, limited No Prefer not to say lot a little 16. If yes, please indicate below (tick all boxes that apply) A condition that substantially Deafness/severe Blindness or severe visual limits one or more basic physical hearing impairment impairment activities such as walking, climbing stairs, lifting or carrying A long-standing Other, including any A learning difficulty psychological or emotional illness condition 17. Do you look after, or give any help or support to family members, friends, neighbours or others because of either: Long term physical/mental ill-health/disability Problems related to old age No Prefer not to say 18. What is your religion or belief? Christian (Church of England, Catholic, Buddhist Hindu Protestant and other Christian denominations) Humanist Jewish Muslim Sikh No religion Other faith or belief
13. What is your age? Up to 14 15-17 18-19 20-29 30-39 40-49 50-59 60-69 70-79 80 or over Prefer not to say 14. What is your ethnic origin? Asian (Bangladeshi) Asian (Chinese) Asian (Indian) Asian (Pakistan) Asian (Other) Black (African) Black (Caribbean) Black (Other) Mixed (White & Asian) Mixed (White & Black Asian) (White & Black Carib) (Other) Other White (Eng/Wels/ Scot/NI/Brit) White (Gypsy/Irish Traveller) White (Irish) (Other) 15. Are your day-to-day activities limited because of a health problem or disability 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 16. If yes, please indicate below (tick all boxes that apply) Deafness/severe hearing impairment Blindness or severe visual impairment A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, lifting or carrying A learning difficulty A long-standing psychological or emotional condition Other, including any illness 17. Do you look after, or give any help or support to family members, friends, neighbours or others because of either: Long term physical/mental ill-health/disability Problems related to old age No Prefer not to say 18. What is your religion or belief? Buddhist Christian (Church of England, Catholic, Protestant and other Christian denominations) Hindu Humanist Jewish Muslim Sikh No religion Other faith or belief
comments_form.docx