Application Monitoring Form

Age Age Under 18 19-24 25-35 36-45 46-55 56-65 65+ Prefer not to say

New Field New Field Disability Hidden

Do you consider yourself to have a long term health condition? Do you consider yourself to have a long term health condition? Yes No Prefer not to say

Sexuality Sexuality Heterosexual Gay Lesbian Bi sexual Other Prefer not to say

Gender Gender Male Female Identify as another gender Prefer not to say

Do you identify now as the same gender as you were at birth? Do you identify now as the same gender as you were at birth? Yes No Prefer not to say

New Field New Field Marital Status Hidden

Are you married or in a civil partnership? Are you married or in a civil partnership? Yes No Prefer not to say

New Field New Field Ethnicity Hidden

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box. Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box. White Mixed / multiple ethnic groups Asian Other ethnic groups

White White Welsh English Northern Irish Scottish British Irish Gypsy or Irish Traveller Other Prefer not to say

Mixed / multiple ethnic groups Mixed / multiple ethnic groups White and black Caribbean White and black African White and Asian Other Prefer not to say

Asian Asian Indian Pakistani Chinese Bangladeshi Other Prefer not to say

Other ethnic groups Other ethnic groups African Caribbean Arab Other Prefer not to say

What is your religion or belief? What is your religion or belief? No religion or belief Christian Hindu Buddhist Jewish Muslim Sikh Prefer not to say Other

Do you have caring responsibilities? If yes, please tick all that apply Do you have caring responsibilities? If yes, please tick all that apply None Primary carer of disabled adult (18 and over) Primary carer of a child/children (under 18) Primary carer of older person Primary carer of disabled child/children Secondary carer (another person carries out the main caring role) Prefer not to say Other