Diversity Questionnaire

The completion of this form, or any part of it, is voluntary

Ascham Homes is committed to equality of opportunity, both in the provision of service and in our role as an employer. We believe that all people have the right to be treated with dignity and respect. We are committed to the elimination of unfair discrimination and we are determined to ensure that all our service users receive fair and equitable treatment.

We would be grateful if you would complete the monitoring information below. The purpose of this information is to assist in monitoring fair and effective service delivery and to develop our policies and practices. The information will be treated and maintained confidentially and will be used for monitoring and to identify service improvements only. No personal information, such as your name or address, will be released when reporting statistical data.

Please read the instructions before answering each question carefully.

All information that you give will be completely confidential. It will only be used to monitor Ascham Homes performance.

First Name

Second Name

House/Flat number

Postcode

Rent reference number

What is your ethnic group? Please indicate your cultural background.

White

Black or Black British

Dual or Multiple Heritage

Asian or Asian British

If you selected other, please specify your ethnic group

Do you consider yourself to have a disability as defined in the Disability Discrimination Act 1995. The Act defines disability as: “a physical or mental impairment which has substantial and long-term effect on a person’s ability to carry out normal day to day activities”.

Yes
No

If ‘YES’ please identify which type of disability from the options below

Hearing disability
Learning disability
Physical disability
Visual disability

Other - please specify

Monitoring Gender

Female
Male
Transgender

Please state your date of birth

Day

Month

Year

Monitoring Religion - please select your religion

Other - please specify

Monitoring Sexual Orientation - What is your sexual orientation

Bisexual
Gay Man
Heterosexual
Lesbian

If English is not your first language and you need to be contacted in another language, please indicate your main:

Other, please specify

Is there anything else that you would like to tell us about yourself, which would help us to improve the service that we provide to you?