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Orkney Islands Area Licensing Board

Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012

Equality Monitoring Form

Why are we asking these questions?

The Orkney Islands Area Licensing Board wants to ensure that its services are available to everyone who lives in Orkney. We recognise that people have different needs and that services sometimes have to be adapted to meet different needs.

This questionnaire helps us to see if we are meeting the various needs or how we can do better.

How will this information be used?

The information on this form will be anonymous. It will be stored and analysed separately from any other personal information you may give. The results will be published in such a way that individuals who have contributed to the survey cannot be identified.

Do I have to give this information?

You do not have to fill this form in, but doing so will help us monitor and improve our services.

QUESTIONNAIRE

  1. What is your date of birth?

    • I do not wish to answer

  2. Are you male or female? Please tick

    • male
    • female
    • I do not wish to answer

  3. Do you identify as transgender (a person who lives, or wants to live, full time in the gender opposite to that they were assigned at birth)? Please tick

    • Yes
    • No
    • I do not wish to answer

  4. Which of the following best describes how you think of yourself?

    • Heterosexual/straight
    • Gay/Lesbian
    • Bisexual
    • Other
    • I do not wish to answer

  5. How would you describe your marital status?

    • Single
    • Married / Civil Partnership
    • Living with partner
    • Separated
    • Divorced
    • Widowed
    • I do not wish to answer

  6. What is your ethnic group?

    Choose ONE section from A to F, and then tick ONE box which best describes your ethnic group or background.

    A: WHITE

    • Scottish
    • Other British
    • Irish
    • Gypsy/Traveller
    • Polish
    • Other White ethnic Group, please write in the box below

    B: MIXED or MULTIPLE ETHNIC GROUPS

    • Any mixed or multiple ethnic groups, please write in the box below

    C: ASIAN, ASIAN SCOTTISH or ASIAN BRITISH

    • Pakistani, Pakistani Scottish or Pakistani British
    • Indian, Indian Scottish or Indian British
    • Bangladeshi, Bangladeshi Scottish or Bangladeshi British
    • Chinese, Chinese Scottish or Chinese British
    • Other, please write in the box below

    D: AFRICAN

    • African, African Scottish or African British
    • Other, please write in the box below

    E: CARIBBEAN OR BLACK

    • Caribbean, Caribbean Scottish or Caribbean British
    • Black, Black Scottish or Black British
    • Other, please write in the box below

    F: OTHER ETHNIC GROUP

    • Arab, Arab Scottish or Arab British
    • Other, please write in the box below
    • I do not wish to answer

  7. What religion, religious denomination or body do you belong to?

    • None
    • Church of Scotland
    • Roman Catholic
    • Other Christian
    • Muslim
    • Buddhist
    • Seikh
    • Jewish
    • Hindu
    • Pagan
    • Another religion, please write in the box below
    • I do not wish to answer

  8. Do you have a physical or mental health condition or illness lasting, or expected to last, 12 months or more?

    • Yes
    • No
    • I do not wish to answer

  9. If the answer to question 8 is yes, does this condition or illness affect you in any of the following areas? Tick all that apply

    • Vision (for example blindness or partial sight)
    • Hearing (for example deafness or partial hearing)
    • Mobility (for example walking short distances or climbing stairs)
    • Dexterity (for example lifting or carrying objects, using a keyboard)
    • Learning or understanding or concentrating
    • Memory
    • Stamina or breathing or fatigue
    • Socially or behaviourally (for example associated with autism, attention deficit disorder or Aspergers’ Syndrome)
    • Other, please specify below
    • I do not wish to answer