Gypsy or Traveller 41 White and Black 15 – or Black British Caribbean 42 White and Black African 21 – – Black or Black British African 43 Mixed White and Asian 22 – – Other Black background 49 Other Mixed background 29 Asian or Asian British Indian 50 Arab 31 – Asian or Asian British Pakistani 80 Other Ethnic background 32 – Asian or Asian British Bangladeshi 90 Not known 33 – Chinese 98 Information refused 34 Do you have a disability (Please tick up to TWO options) 00 No known disability / not disabled 56 A physical impairment or mobility issues A specific learning difficulty such as dyslexia, dyspraxia or 51 57 Deaf or serious hearing impairment AD(H)D 52 General learning disability (such as Down’s syndrome) 58 or a serious visual impairment A social/communication impairment such as Asperger's A disability, impairment or medical condition that 53 96 syndrome/other autistic spectrum disorder is not listed above A long standing illness or health condition such as cancer, 54 97 Prefer not to say HIV, diabetes, chronic heart disease, or epilepsy A mental health condition, such as depression, 55 schizophrenia or anxiety disorder What is your gender? (Please tick one option only) 1 Male 2 Female Is your gender identity the same as the gender you were originally assigned at birth? (Please tick one option only) 01 Yes 98 Information refused 02 No What is your religion? (Please tick one option only) 01 No religion 12 Muslim 02 Buddhist 13 Sikh 03 Christian 14 Spiritual 10 Hindu 80 Any other religion or belief 11 Jewish 98 Prefer not to say Sexual orientation (Please tick one option only) 01 Bisexual 04 Heterosexual 02 Gay man 05 Other 03 Gay woman / lesbian 98 Information refused
15 Gypsy or Traveller 41 – White and Black 21 or Black British – Caribbean 42 – White and Black African 22 Black or Black British – African 43 Mixed – White and Asian 29 Other Black background 49 Other Mixed background 31 Asian or Asian British – Indian 50 Arab 32 Asian or Asian British – Pakistani 80 Other Ethnic background 33 Asian or Asian British – Bangladeshi 90 Not known 34 Chinese 98 Information refused Do you have a disability (Please tick up to TWO options) 00 No known disability / not disabled 56 A physical impairment or mobility issues 51 A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D 57 Deaf or serious hearing impairment 52 General learning disability (such as Down’s syndrome) 58 or a serious visual impairment 53 A social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder 96 A disability, impairment or medical condition that is not listed above 54 A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy 97 Prefer not to say 55 A mental health condition, such as depression, schizophrenia or anxiety disorder What is your gender? (Please tick one option only) 1 Male 2 Female 01 Yes 98 Information refused 02 No Is your gender identity the same as the gender you were originally assigned at birth? (Please tick one option only) 01 No religion 12 Muslim 02 Buddhist 13 Sikh 03 Christian 14 Spiritual 10 Hindu 80 Any other religion or belief 11 Jewish 98 Prefer not to say What is your religion? (Please tick one option only) Sexual orientation (Please tick one option only) 01 Bisexual 04 Heterosexual 02 Gay man 05 Other 03 Gay woman / lesbian 98 Information refused
EE-Fee-Claim-Form.docx