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Cymraeg

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Tell us about yourself

Gathering your feedback and equality, diversity and inclusion information.

Learn more

Home
Tell us about yourself

If you require this form in another language, please email Comms@v2c.org.uk. If you would prefer to complete the form over the phone, please call us on 0300 123 2100.

EDI Data Collection

Step 1 of 4

25%

Are you a contract holder?(Required)

Yes

No

This includes tenants, joint-tenants and leaseholders.

Name(Required)

First Last

Date of birth(Required)

DD slash MM slash YYYY

Address(Required)

House number or flat Street name Town County Postcode

Please complete the form about yourself and not other people in your household. This information will be kept in your personal records, not your household. This information will be used to monitor our services and will not be passed onto any third party.

Please select an option(Required)

I am happy to share my information

I do not wish to complete this form now or in the future

Ethnicity

How would you describe your ethnic group?

Any other white backgrounds: write in(Required)

Any other Mixed or multiple ethnic groups: write in(Required)

Any other Asian, Asian Welsh, Asian British: write in(Required)

Any other Black, Black Welsh, Black British: write in(Required)

Other ethnic group: write in(Required)

Sex, Gender & Sexual Orientation

What is your sex at birth?

Other: write in(Required)

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

If no, please write gender identity(Required)

Which of the following best describes your sexual orientation?

Other, please specify(Required)

Age & Marital Status

What is your age group?

What is your legal marital or registered civil partnership status?

Disability, Health & Care

Do you have any physical or mental health conditions, illnesses or impairments lasting or expected to last 12 months or more?

Do any of your conditions, illnesses or impairments reduce your ability to carry out day to day activities?

Select all that apply

Deafness or hearing impairment

Blindness or vision impairment

Physical disability/ impairment or mobility loss

Learning difficulties such as dyslexia

Mental health condition such as depression or schizophrenia

Social/communication impairment such as Aspergers or other autistic spectrum disorder

A disability, impairment or medical condition that is not listed above

Prefer not to say

A disability, impairment or medical condition that is not listed above

Is there anything that Valleys to Coast can do to help support you with your disability, illness or impairment?

Do you look after, or give any help or support to anyone because they have long term physical or mental health conditions, illnesses, impairments or problems related to old age?

Religion & Language

What is your religion?

Other(Required)

Can you understand, speak, read or write Welsh? (tick all that apply)

Understand spoken Welsh

Speak Welsh

Read Welsh

Write Welsh

None

Prefer not to say

What is your main language?

Other

How well can you speak English?

I confirm that the information I have submitted is true and correct(Required)

Confirm

Δ

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