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Blaenau Gwent Diversity Form
Blaenau Gwent Diversity Monitoring Form
Please fill in our diversity form. This is used to indicate the demographics of people reached in the programme, and will not be used for any other purpose, and is in line with UK GDPR requirements.
Gender
Male
Female
Transgender
I consider myself to be gender neutral
Other
Prefer not to say
If you have stated 'Other' please specify:
Age
Under 16
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Marital Status
Single
Married
Civil Partnership
Living with my partner
Prefer not to say
If you have stated 'Other' please specify:
Ethnicity
White British
White Irish
Eastern European
Western Eurpoean
Gypsy/Traveller
Other White Background
Black British
Black Caribbean
Black African
Black Somali
Black Yemeni
Black Congolese
Black Portuguese
Black American
Asian British
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian Chinese
Asian Vietnamese
Asian Turkish
Other Asian Background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Other Mixed Background
My Ethnicity Is Not Listed Above
Other
If you have stated 'Other' please specify:
Religion or Belief
No religious belief
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
If you have stated 'Other' please specify:
Do you have a disability?
No
Yes - Physical Impairment
Yes - Sensory Impairment
Yes - Mental Health
Yes - Learning Disability or Difficulty
Yes - Long Standing or Progressive Illness or Health Condition
Prefer not to say
If you have stated 'Other' please specify:
Sexual Orientation
Heterosexual
Homosexual (Gay Man)
Homosexual (Gay Woman/ Lesbian)
Bisexual
Prefer not to say
Other
If you have stated 'Other' please specify:
Employment
Full Time
Part Time
Unemployed
Student
Carer
Retired
If you have stated 'Other' please specify:
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