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THE BROOMHOUSE CENTRE

79/89 Broomhouse Crescent
Edinburgh EH11 3RH
Tel/Fax: 0131 455 7731
Email:
Website:

EQUALITIES MONITORING FORM

Please help us by filling in this form and telling us about yourself. By answering the questions you will help us to:

  • meet our commitment to promote equality and diversity in everything we do
  • better tailor services to meet your needs
  • ensure that there are no barriers which make it difficult for you to use any of our services
  • identify which groups in the community are not represented or using services and take steps to address any gaps
  • measure the outcomes of our services and promote equality

The information you give us is confidential and your individual details will not be shared with others and will be stored securely. If you have any questions, please ask and we will help you. If you do not wish to complete some sections ofthis form, you do not have to and this will not affect your rights or entitlement to services.

1. How well do you speak English?
Very well / Quite well / A little / No English
2. What is your main language?
Tick one:
Arabic Gaelic Russian
Bengali PolishSign/BSL
Chinese PortugueseTurkish
English RomanianUrdu/Punjabi
Other, please tell us ______
3. What age group are you in? (please tick one)
Under13 / 13-15 / 16-19 / 20-29
30-39 / 40-49 / 50-59 / 60-69
70-79 / 80-89 / 90+ / Prefer not to answer
4. What is your sex?
Female / Male / Other / Prefer not to answer
5. Gender Identity – Do you or have you ever identified yourself as transgender?
Yes / No / Prefer not to answer
6. What is your sexual orientation?
Bisexual
(both sexes) / Gay / Lesbian
(same sex)
Heterosexual / Straight
(opposite sex) / Prefer not to answer
7. What is your employment status? (please tick all that apply)
Employed full time / Employed part time / Unemployed / Looking
for work
Currently unfit to work / Student / Retired / Carer
Other, please write in e.g. volunteering______
Prefer not to answer
8. What religion, religious denomination or body do you belong to?
Church ofScotland / Roman Catholic / Other Christian
Buddhist / Hindu / Jewish
Muslim / Pagan / Sikh
None / Another religion
Other, please write in ______
Prefer not to answer
9. What is your ethnic group?
Choose ONE section from A to F, and then tick ONEBOX ONLY which best describes your ethnic group or background.
A. White
Scottish / Other British / Irish
Gypsy/ Traveller / Polish
Other white ethnic group, please write in______
B. Mixed or multiple ethnic group
Any mixed or multiple ethnic groups, please write in
C. Asian, Asian Scottish or Asian British
Pakistani, Pakistani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other, please write in______
D. African
African, African Scottish or African British
Black, Black Scottish or Black British
Other, please write in______
E. Caribbean or Black
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Other, please write in______
F. / Other ethnic group
Arab, Arab Scottish or Arab British
Other, please write in______
G. / Prefer not to answer
10. Impacts on health
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? Include problems related to older age. Please tick ONE.
Yes/Limited a lot / Yes/Limited a little / No
Prefer not to answer
11. Do you require a Carer or Personal Assistant?
Yes / No / Prefer not to answer
Disability or Long Term Health - Impairments
12. Does the condition or illness affect you in any of the following areas?
Tick all that apply:
Deafness or severe hearing impairment
Blindness or severe visual impairment
Mobility - difficulty in walking short distances or
climbing stairs
Dexterity – difficulty in lifting or carrying objects,
using a keyboard
Learning or understanding or concentrating
Memory
Mental health
Stamina or breathing or fatigue
Socially or behaviourally, for example Autism,
Attention Deficit Disorder or Aspergers’ syndrome
A chronic illness (such as cancer, HIV, diabetes,
heart disease or epilepsy)
Other condition that affects your ability to carry out
everyday tasks
None
Prefer not to answer
13. What is the first part of your postcode? e.g. EH11 2
(first five digits only)
Prefer not to answer
14. Has someone helped you to complete this form?
Yes No
Prefer not to answer

Thank you for completing this form.

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