Dementia Session Participant Equality Monitoring Form Dementia Equality Monitoring Form South Gloucestershire Dementia Friendly Communities is working towards equality of opportunity for all who use its services. We are actively opposed to discrimination and want to ensure we support diversity and accessibility. We believe that monitoring the use of our services will help us assess any areas requiring improvement. Therefore, we would be grateful if you would complete this form. This information is anonymous and will remain confidential, to be used solely for the purpose of monitoring and reporting to our funders. Please note, your help in this matter is entirely voluntary. Ethnic Origin * Arab Asian/Asian British – Bangladeshi Asian/Asian British – Indian Asian/Asian British – Pakistani Asian/Asian British – Chinese Asian/Asian British – Other (please state)Asian/Asian British – Other (please state) Black/African/Caribbean/Black British – African Black/African/Caribbean/Black British – Caribbean Black/African/Caribbean/Black British – Other (please state)Black/African/Caribbean/Black British – Other (please state) Gypsy or Traveller of Irish Heritage Mixed/Multiple Ethnic Groups – White & Asian Mixed/Multiple Ethnic Groups – White & Black African Mixed/Multiple Ethnic Groups – White & Black Caribbean Mixed/Multiple Ethnic Groups – Other (please state)Mixed/Multiple Ethnic Groups – Other (please state) White – English/Welsh/Scottish/Northern Irish/British White – Irish White – Other (please state)White – Other (please state) Prefer not to say Other ethnic group (please state)Other ethnic group (please state) Religion or belief * Christian Catholic Muslim Hindu Sikh Jewish Buddhist Jehovah’s Witness Mormon Brethren Rastafari None Humanist Pagan Wiccan OtherOther Prefer not to say Your Gender * Male Female Transgender Gender fluid OtherOther Age * Under 18 19 – 24 25 – 44 45 – 64 65 – 74 Over 75 Prefer not to say Sexual Orientation * Heterosexual Gay man Bisexual Lesbian / gay woman Pan sexual OtherOther Prefer not to say Do you consider yourself to be disabled? * Yes - Physical Impairment, such as difficulty using arms or mobility issues which means using a wheelchair or crutches. Yes - Sensory impairment, such as being blind / having a serious visual impairment or being deaf / have a serious hearing impairment. Yes - Mental health condition, such as depression, schizophrenia or dementia Yes - Learning disability/difficulty (such as Down’s syndrome or dyslexia) or cognitive impairment such as autistic spectrum disorder. Yes - Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy. Yes - OtherYes - Other No Prefer not to say Do you consider yourself to be a carer? * Yes, on average caring for over 50 hours per week Yes, on average caring for under 50 hours per week No Prefer not to say How did you hear about this session? * Social Media Leaflet / poster Community Group Word of mouth The organisation I work for OtherOther Prefer not to say If you are human, leave this field blank. Submit
