Copy of Equal Opportunities Monitoring for Patient and Public Engagement Network

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* 1. Today's Date

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* 2. Gender (please tick)

Man

Woman

Non-binary

Prefer not to say

Other (please specify)

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* 3. Is your gender identify the same as the gender you were originally assigned at birth (please tick as appropriate)

Yes

Prefer not to say

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* 4. Age Group

Under 18

18 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 or over

Prefer not to say

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* 5. Which of the following best describes your sexual orientation (please tick the correct box)

Heterosexual/straight

Lesbian/Gay Women

Gay Man

Bisexual

Prefer not to say

Other (please specify)

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* 6. Which of the following best describes your religion or belief

No religion

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Prefer not to say

Other (please specify)

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* 7. How would you describe yourself? Using the following classifications, how would you describe your ethnic origin

White British

Irish

Gypsy/Irish Traveller

Polish

All white groups

White and Black Caribbean

White and Black African

White and Asian

Indian

Pakistani

Bangladeshi

All Asian groups

Caribbean

African

All black background

Somali

Irish Traveller

Romany

Arab

Prefer not to say

Other (please specify)

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* 8. Do you consider yourself to have a disability/impairment?

Yes (please tick from below the appropriate box)

Physical disability

Sensory disability

Speech and language difficulty

Learning difficulty

Autism

Diagnosis of Cancer, HIV+ or Multiple Sclerosis

Other progressive disabilities

Mental health issues

Hidden disability, such as Epilepsy or IBS

Other (please specify)

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* 9. Do you have caring responsibilities? If yes, please tick all that apply

Primary carer of a child/children (under 18)

None

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role))

Prefer not to say

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* 10. Refugees and Asylum Seekers

A refugee

An asylum seeker

What country/region are you a refugee/asylum seeker from ( please state here)

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* 1. Today's Date

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* 2. Gender (please tick)

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* 3. Is your gender identify the same as the gender you were originally assigned at birth (please tick as appropriate)

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* 4. Age Group

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* 5. Which of the following best describes your sexual orientation (please tick the correct box)

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* 6. Which of the following best describes your religion or belief

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* 7. How would you describe yourself? Using the following classifications, how would you describe your ethnic origin

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* 8. Do you consider yourself to have a disability/impairment?

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* 9. Do you have caring responsibilities? If yes, please tick all that apply

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* 10. Refugees and Asylum Seekers

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* 11. Language: please state your commonly spoken language