African and Caribbean Mental Health Services

AFRICAN AND CARIBBEAN MENTAL HEALTH SERVICES

Equality and Diversity Monitoring Form

The African and Caribbean Mental Health Services operates an equal opportunity policy. The information in this section is strictly confidential and is covered by the Data Protection Act 2003.

Please tick one of the boxes

Are youMaleFemale

Is your gender identity the same as the gender you were assigned at birth?

YesNo

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

Heterosexual GayLesbianBisexual

Prefer not to sayOther

Age16 – 1819 – 30

31 – 4041 – 50

51 – 6061+

Marital status

SingleMarriedCivil partnership Separated

DivorcedWidowedPrefer not to say

Are you currently pregnant or have had a baby in the last 12 months?

YesNoPrefer not to say

Faith/Religion/Beliefs

ChristianJudaismBuddhismSikhism

RastafarianHinduismIslamOther

NonePrefer not to say

Employment status

Full-timePart-timeVolunteerStudent

UnemployedHomemakerRetiredMilitary veteran

Prefer not to say

Forensic history

Please tick:

YesNoPrefer not to say

Disability

A disabled person is defined in the Disability Discrimination Act 2005 as someone with a physical or mental impairment that has a substantial and long term impact on their ability to carry out day to day activities. This definition also covers HIV, cancer, multiple sclerosis, hearing, oral or learning impairment and any progressive or life long conditions.

Having read this, do you consider yourself to be covered by the definition?

YesNoPrefer not to say

If yes, please tick the relevant box/es

Mental healthPhysical disabilityHearing impairment

Learning disabilitySight impairmentLong term health condition

Other

If specific arrangements are required or to declare a statement of disability, please state here:

______

______

Choose one section from A to F, then tick the appropriate box to indicate your cultural background:

A: Black, Black British, Black English, Black Scottish or Black Welsh
Caribbean
African
Any other Black background, please specify:
______/ B: Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background, please specify:
______/ C: Asian, Asian British, Asian English, Asian Scottish or Asian Welsh
Indian
Pakistani
Bangladeshi
Any other Asian background, please specify:
______
D: White
British
English
Scottish
Welsh
Other, please specify:
______
Irish
Any other White background, please specify:
______/ E: Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh or other ethnic group
Chinese
Any other Asian background, please specify:
______/ F: Any other ethnic group
______

May 2011

Updated May 2014