CIH is committed to ensuring that its services are accessible to everyone regardless of race, gender, ability, religion, sexual orientation or age. The information you provide on this form will help us comply with our policy of ensuring equality in our services to you.

We recognise that some people may regard some of this information as personal and we have, therefore, included an option in most questions for “prefer not to say”. You do not have to complete all of this form but it will help us improve our services if you can complete as much as possible and return the form. Your submission will be made anonymously so the information you provide here will not be associated with your other personal details.

All information CIH collects around equality and diversity will be treated confidentially in accordance with the Data Protection Act and will be stored on the CIH database. Access to this information will be restricted to staff involved in the processing and monitoring of this data. It will be used to provide statistical information only.

* 1. Are you;

* 2. Date of Birth (leave blank if you'd prefer not to say)

Date

* 3. The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term effect (e.g. has lasted or is expected to last at least 12 months) on the person’s ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability according to the terms given in the Equality Act 2010?

* 4. If yes, please indicate the type of impairment that applies to you. Please tick all that apply. If your disability does not fit any of these types, please mark other and specify.

T