Protected Characteristics Questionnaire Name * First Name Last Name Email * Client reference number * Please confirm your gender identity: Male Female Non-Binary Intersex Gender Queer Other Declined to answer Are you transgender? Yes No I don't know Declined to answer Ethnicity White: British Irish Gypsy or Irish Traveller Eastern European Roma Any other white background If you selected "any other white background" above, please provide further information here (optional): Mixed/Multiple Ethnic Background White & Black Caribbean White & Black African White and Asian Any other mixed/multiple If you selected "any other mixed/multiple" above, please provide further information here (optional): Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background If you selected "any other Asian background" above, please provide further information here (optional): Black/African/Caribbean/Black British African Caribbean Any other Black/African/Caribbean background If you selected "any other Black/African/Caribbean background" above, please provide further information here (optional): Other Ethnic Group Arab Any other ethnic group If you selected "any other ethnic group" above, please provide further information here (optional): Ethnicity: Prefer not to say I would prefer not to disclose my ethnicity Disability I have a disability I do not have a disability If you have indicated that you have a disability, please select the nature of your disability from the drop down list: Physical Disability Learning Disability Hearing Disability Vision Disability Mental Health Disability Long term Condition Speech Impairment Other Disability If you have selected "other disability" above, please provide further information here (optional): Please confirm your preferred pronouns: Relationship status Civil Partnership Cohabiting Divorced In relationship but not cohabiting Married Separated Single Widowed Prefer not to say Religion Please confirm your religion: Bahai Buddhist Christian Hindu Jain Jewish Muslim Shinto Sikh Zoroastrian Prefer not to say Sexual Orientation Please confirm your sexual orientation: Heterosexual Gay Lesbian Queer Bisexual Asexual Pansexual Other Prefer not to say If you have selected "other" above, please provide further information here (optional): Thank you!
