LINks Stockports community voice

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Diversity Monitoring Form

Please use the form provided below to provide information directly online or if you prefer you can download a hard copy by clicking here.

It would be very helpful if you would complete this form as fully as possible. We monitor this information to ensure that the LINk is available to all members of our community including those who may traditionally be under represented. This information that you provide on this form will be held in confidence, in accordance with the Data Protection Act 1998. It will be used only as part of a wider analysis, no individuals will be identifiable through this exercise and under no circumstances will
information be passed to any other party. You are under no obligation to complete this form, however if you could return this with your application form, your support would be appreciated. Many thanks.

Gender:	Male Female
Age:
Post code:
Sexual Orientation: (how you define your sexual orientation)	Gay Lesbian Bisexual Heterosexual Prefer not to say
Which of these activities best describe your situation?	Full time work Part time work Self employed Government Scheme Full time education Unemployed due to illness/disability Wholly Retired Looking after the home Other (please specify below)
Do you consider yourself to have a disability? Under the Disability Discrimination Act 1995 a person is considered to have a disability if he/she has a physical or mental impairment or illness such as HIV, cancer, diabetes, heart conditions etc. Which has sustained and long term adverse effect on his or her ability to carry out normal day-to-day activities.	Yes No
Disability: If you have answered ‘yes’ to having a disability how would you describe your impairment?	Physical Impairment Visual Impairment Learning Disability Mental Health/Mental Distress Hearing Impairment/Deaf Long Term Limiting Illness Other (please specify below)
Religion / Faith Do you have a religion or faith?	Yes No If YES please select: Buddhist Christian Hindu Jewish Muslim Sikh Another religion or faith (please specify below)
Ethnic Origin: Do you identify as:	White: English Welsh Scottish Irish Other White European Other White non-European Mixed / Duel Heritage: White Asian White/Black African White/Black Carribbean Other Mixed Heritage (please specify below) Black: Caribbean African Other Black Heritage (please specify below) Asian: Indian Pakistan Bangladeshi Other Asian Heritage (please specify below) Other Ethnic Origin: Chinese Traveller/Gypsy Other Ethnic Group (please specify below)
Carer: Is there someone who relies on you for day to day care and attention?	Yes No if YES are they: Children A family Member Partner Friend

Many thanks for your time. The data you provide will be used to contact you about Local Involvement Networks or other health and social care issues and will be stored in accordance with the Data Protection Act.

Stockport LINk is supported through Pebble Enterprises
Co No 06506546, Charity No 1139131