Male ___Female___ Prefer not to say___If you are undergoing the process of gender
reassignment, please tick the box that applies
to your future gender.
What age group do you belong to?
___18-25 ___25-35 ___35-45 ___ 45-55 ___over
55 ___Prefer not to say
How would you describe your sexuality?
___heterosexual/straight ___gay man ___gay
woman/lesbian ___bi-sexual ___Prefer not
Do you consider that you have a disability?
___Yes ___No ___Prefer not to say
Do you have a disability as defined by the
Disability Discrimination Act?
___Yes ___No ___I don't know ___Prefer
not to say
Do you consider that you have a long-term
How would you describe your religion or belief?
My religion or belief is ____________________________________________
___I have no religion or belief.___Prefer not to say
How would you describe your nationality?
___British ___English ___Scottish ___Welsh
___Irish __Other (please describe) ____________
How would you describe your ethnic origin?
___White/Mixed___White ___White and Black
Caribbean ___White and Black African
___White and Asian
Any other Mixed background (please describe)
___Asian ___Indian ___Pakistani ___Bangladeshi
Any other Asian background (please describe)
Any other Black background (please describe)
Any other ethnic group/background, please
___Prefer not to say
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