Equality and monitoring form

Equality monitoring form

The NHS South East London  would like membership of the committee/ boards to have a broad reflection of different communities across south east London to help us plan and monitor relevant engagement across diverse communities.  The individual information on this form will be kept confidential by the NHS South East London.

Please select what you consider your ethnic origin to be.

Ethnicity is distinct from nationality

1.  

White

2.  

Black or Black British

3.  

Asian or Asian British

4.  

Mixed or Multiple ethnic groups

5.  

Other ethnic group

6.  

Prefer not to say

7.  

Gender

8.  

Gender reassignment - does your gender differ from your birth sex?

9.  

Religion or belief 

10.  

Sexual orientation 

Pregnancy and maternity 

11.  

Are you pregnant?

12.  

Have you had a baby in the last 12 months? 

13.  

Marriage or civil partnership

14.  

Age

15.  

Disability - Do you have any of the following conditions that have lasted or are expected to last for at least 12 months?

16.  

Are you a carer? (for a friend or family member)