Gender monitoring Would you describe yourself as: Male Female Non-binary Prefer not to say If you prefer to use your own term, please specify here ……………………. Age monitoring To which age band do you belong? 16 19 20 24 25 29 30 34 – – – – 35 39 40 44 45 49 50 54 – – – – 55 59 60 64 65 69 70 74 – – – – 75 + Prefer not to say Disability monitoring The Equality Act 2010 (Disability Discrimination Act 1995) has defined disability as or mental impairment which has a substantial and long-term follows; “A physical adverse effect on your ability to carry out normal day-to-day activities” Do you consider yourself to have a disability or a long-term health condition? Yes No If yes, what is the effect or impact of your disability or health condition? Prefer not to say
Gender monitoring Would you describe yourself as: Male Female Non-binary Prefer not to say If you prefer to use your own term, please specify here ……………………. Age monitoring To which age band do you belong? 16 – 19 20 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 – 69 70 – 74 75 + Prefer not to say Disability monitoring The Equality Act 2010 (Disability Discrimination Act 1995) has defined disability as follows; “A physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities” Do you consider yourself to have a disability or a long-term health condition? Yes No If yes, what is the effect or impact of your disability or health condition? Prefer not to say
5.-equal-opps-monitoring-form---august-2017.docx