Section 75 Home Safety

2. Is the gender you identify with the same as your sex registered at birth?

Yes No (write in gender identity) Prefer not to say

Gender identity

3. What is your country of birth?

Northern Ireland England Republic of Ireland Scotland Wales Prefer not to say

Elsewhere (please specify)

4. What is your ethnic group?

White Black African Black other Chinese Filipino Indian Irish Traveller Roma

Any Other (please specify)

There is a limit of 30 characters

5. Disability In accordance with the Disability Discrimination Act 1995, a disability is defined as a physical or mental impairment which has a substantial and long-term effect on a person's ability to carry out normal day-to-day activities. Under this definition, do you consider yourself as having a disability?

Yes No Prefer not to say

6. If yes, please indicate which type of impairment(s) applies to you. Please tick all that apply

Physical Impairment eg. difficulty using arms or requiring a wheelchair or crutches Sensory Impairment, such as blind/visual impairment or deaf/hearing impairment Mental health condition eg. depression or schizophrenia Autism Spectrum Disorder; Dyslexia; Cognitive Impairment; Learninig disability Long standing illness, such as cancer, HIV, diabetes, chronic heart disease or epilepsy Prefer not to say Other (please specify)

Please specify

7. How would you describe your sexual Orientation?

Bisexual Gay Heterosexual Lesbian Prefer not to say

Other (please specify)

8. How would you describe your caring responsibilities? (please tick all that apply)

Child(ren) under 18 An older person A person with a disability None Prefer not to say

Other (please specify)

9. Please indicate your religion?

Buddhist Catholic Hindu Jewish Muslim Protestant Sikh Prefer not to say None

Other (please specify)

10. Please indicate your marital status?

Cohabiting Divorced/Dissolved Civil Partnership Married/Civil Partnership Separated Single Widowed Prefer not to say

Other (please specify)

11. How would you describe your political opinion?

Broadly Nationalist Broadly Unionist Prefer not to say

Other (please specify)

Section 75: Equality Monitoring Form