(WRDA Bowel) Breast, Cervical and Bowel Screening Awareness Programme Equal Opportunity form

Cervical Screening Awareness Session Equal Opportunity Form

By filling out this form you help us ensure we are reaching all sections of the community. You will be prompted to fill out a brief questionnaire about your knowledge of Bowel Screening at the end of this form and then you will receive the video link.

The information you provide in this survey is anonymous. It may be shared with our funder, the PHA.

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* 1. Please enter your postcode

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* 2. Please indicate your marital status.

Single

Married

Separated

Divorced

Widowed

Cohabiting

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* 3. Please indicate your employment status

Full Time

Part Time

Unemployed

Retired

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* 4. Please indicate your religious or community background

I am a member of the Protestant Community

I am a member of the Catholic Community

Other

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* 5. Please indicate your caring status

No caring responsibilities

Care for own children

Care for other relative

Other caring responsibility

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* 6. Disability Status

I do not have a disability/Illness

I do have a disability/Illness

Physical disability

Mental Illness

Learning disability

Other

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* 7. Please indicate your ethnic origin

Chinese

Irish Traveller

Indian

Black/African-Caribbean

Pakistani

White

Asian

Other

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* 8. Please indicate your age range

18-24

25-49

50-69

70+

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* 9. Please indicate your sexual orientation

Lesbian

Gay

Bisexual

Heterosexual

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* 10. Please indicate your gender identity

I am a woman

I am a man

Trans history

I am a non-binary person