We would be grateful if you would answer the following questions which are entirely optional. If you are not comfortable answering any particular question, please tick the box 'prefer not to say'. The questions below to the person who has suffered the problem. If you have complained on behalf of someone else please give information relative to them and not yourself. 

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* 1. What was your age at your last birthday?

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* 2. How would you describe nationality?

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* 3. What is your gender?

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* 4. What is your ethnic group?

  White Asian or Asian British  Mixed or multiple ethnic groups Black, African, Caribbean or Black British Other ethnic group
Ethnicity

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* 5. What is your household's main language?

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* 6. What is your current working status?

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* 7. Which of the following qualifications do you have?

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* 8. Do you consider yourself to be disabled?

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* 9. Which of the following options best describes how you think of yourself?

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* 10. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last at least 12 months

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* 11. If you answered yes to the above, please indicate which of the following best describes how you think of yourself?

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* 12. What is your religion?

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* 13. Which of the following best describes your marital status?

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* 14. Is the gender you identify with the same as the sex you were described at birth?

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* 15. Which of the following options best describes how you think of yourself?

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