1.Gender

Male

Female

Non Binary

Prefer not to say

Prefer to identify own gender

2.Is the gender you identify with the same as your gender registered at birth? 

Yes

No

Prefer not to say

3.What is your sexual orientation?

Heterosexual 

Gay 

Lesbian 

Bisexual 

Asexual 

Pansexual 

Undecided 

Prefer not to say

Prefer to use your own identity

4.Age

16-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

65+ 

Prefer not to say 

5.What is your ethnicity?
Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box

Indian 

Pakistani 

Bangladeshi 

Chinese

African 

Caribbean

Arab

White and Black Caribbean 

White and Black African 

White and Asian

British

English 

Welsh 

Scottish 

Northern Irish 

Irish 

Gypsy or Irish Traveller 

Prefer not to say

Any other background - please write in

6.The Disability Discrimination Act 1995 (DDA) defines a person as disabled if they have a physical or mental impairment which has a substantial and long term (i.e. has lasted or is expected to last at least 12 months) adverse effect on ones ability to carry out normal day-to-day activities. This definition includes conditions such as cancer, HIV, mental illness and learning disabilities.

Do you consider yourself to have a disability according to the above definition?

Yes

No

Prefer not to say

7.If you selected yes, please indicate your disability:

Vision (e.g. blindness or partial sight)

Hearing (e.g. deafness or partial hearing)

Mobility (e.g. difficulty walking short distances, climbing stairs, lifting and carrying)

Learning, concentrating or remembering

Mental health

Stamina or breathing difficulty

Social or behavioural issues (e.g. neuro diverse conditions such as Autism, Attention Deficit Disorder or Asperger’s Syndrome)

Other impairment

Prefer not to say