Equalities Monitoring 

In order to meet your needs and improve service we need to know a bit more about you. Please help us by completing this form which describes how you see yourself. This information will be kept confidential and is for our monitoring use only. 

1)  Ethnic Background  How would you describe your ethnicity? 

a)  Asian or Asian British
	   Bangladeshi          Indian        	    Pakistani     
	   Any other Asian background (please write in) ……………………………….

b)  Black or Black British
	   African 		     Caribbean          Somali        
	   Any other Black background (please write in) ………………………………..

c)  Chinese  
	   Any other Chinese background (please write in)  ……………………………

d)  Dual / Multiple Heritage     
	   Asian & White        Black African & White         Black Caribbean & White 
             Any other Heritage background (please write in)  ……………………………

e)  White 
	   British           	    European             Irish
	   Any other White background (please write in)  ……………………………….

f)  Other ethnic group  
	   Gypsy/Romany/Irish traveller  
	   Any other ethnic group (please write in)  ………………………………………

g)  Prefer not to say	   

2)  Gender identity  How would you describe your gender? 

	  Female		Male		Trans woman 		Trans man 
	  Other …………….		Prefer not to say

3)  Age
	  Date of birth (day/month/year)  …………………………………………………
	  Age in years	    		      …………………………………………………
	  Prefer not to say 

4)  Disability	 

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 (i.e. has lasted or is expected to last at least 12 months) and has an adverse effect on the person’s ability to carry out normal day to day activities.

Do you consider yourself to have a disability, or a long term illness, physical or mental health condition?
	  Yes	  		No		  Prefer not to say

5)  Sexual Orientation how would you describe yourself?
  
	Bisexual        Gay/Lesbian       Heterosexual/straight
  	Prefer not to say 	  	other (please write in) …………………………………

6)  Religion & Belief how would you describe your religion or belief?

  	Bahai		 	Buddhist			  Christian			  Hindu
  	Jain			Jewish			  Muslim			  Sikh
  	Atheist		No religion		  	  Prefer not to say
  	Other (please write in) ……………………………………………………………..

7)  Your Postcode 
    
                           First 4 digits only 
  
	Prefer not to say 

Thank you for completing this monitoring form.  The information you have provided will be kept in accordance with terms of the Data Protection Act 1998 and will only be used for the purpose of monitoring. 

Your details will not be passed on to any other individual, organisation or group. Leicester City Council is the data controller for the information on this form for the purposes of the Data Protection Act.