Background Information Form – South East Leadership Academy

General Data

Please select event:*

Coaching for Improvement Programme

Building a Coaching Culture Programme

NHS Region*

Please indicate your age range below:

Please describe your gender below:

I prefer to self-describe:

Is your gender identity the same as the one you were assigned at birth?

Yes

No

I do not wish to disclose this

I would describe my ethnic origin as:Please tick a category or provide further detail as appropriate

If your ethnic group is not included in the above, please specify below:

Please select the option which best describes your sexuality; Please tick as appropriate:

Please indicate your religion or belief; Please tick as appropriate:

Disability

Many people do not consider themselves to be disabled, but under the Disability Discrimination Act 1995 and the Equality Act 2010, you can consider yourself disabled if you have a physical or mental impairment or long-term health condition, and the effects are expected to last, or have lasted for a year or longer, and have substantial effect on your ability to carry out day-to-day activities; or your day-to-day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin). Taking this into account, do you consider yourself disabled?

Do you consider yourself to have a disability? Please tick as appropriate:

Yes

No

Do not wish to disclose

Unknown

If you answered Yes, please state the type / types of impairment which applies to you, if you are disabled but none of the listed categories apply, please mark Other.

If you selected 'Other' to the previous question, please specify.

What is your role within Health and Social Care?

Do you work or is your primary role in the following area of care:

What is your occupational group?

For NHS and Social Care staff – please select your Agenda for change band

(For non-NHS only) please specify your organisation/career grading

Do you have face-to-face contact with patients / service users are part of your day job?

Yes, frequently

Yes, occasionally

No

Are you still on the register for your professional group?

Yes

No

Not applicable

Equality, Diversity and Inclusion Monitoring Form

General Data

Disability

What is your role within Health and Social Care?