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Hospital: Required
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Your details

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Address: Required
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Service user details (if different from above):

Address:
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Please be aware your complaint/concern will not be reviewed until it reaches the central Complaints department. If you need to speak to someone more urgently, then please inform a member of staff or call our crisis team on NHS 111 (selecting option 2).

Equality and Diversity Monitoring Form

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) has a public duty to promote race equality, disability equality and gender equality. The Equality Act 2010 extends equality legislation to fully cover the following issues.

Race
Age
Disability (including reasonable adjustments)
Sexual Orientation
Sex
Religion or Belief
Maternity and Pregnancy
Marriage and Civil Partnership
Gender Reassignment, expression and identity


The Trust as a responsive service provider wishes to monitor equality and diversity information provided by those making complaints. All the information we receive will be used and treated with the strictest confidence. Any information released will be anonymous with all names removed.

There is no obligation to complete this section, but any information that you can provide will help us to provide a better service.

A.  Disability

The Equality Act 2010 protects disabled people. The Act sets out the circumstances in which a person is ‘disabled’. It says you are disabled if you have:

A mental or physical impairment that has an adverse effect on your ability to carry out normal day-to-day activities (meaning it has lasted 12 months, or is likely to last for 12 months or more)

There are some special provisions, for example:

If your disability has badly affected your ability to carry out normal day-to-day activities, but it doesn’t anymore, it will still be counted as having that effect if it is likely to do so again.

If you have a progressive condition and it will badly affect your ability to carry out normal day-to-day activities in the future, it will be treated as having a bad effect on you now.

Cancer, HIV infections, and multiple sclerosis are covered effectively from the point of diagnosis. Past disabilities are covered.

C

Taking this into consideration, do you consider yourself to have a disability?
Are there any reasonable adjustments that you would like us to consider in order to improve and support communications?

B. Ethnicity

Please note we are not asking about citizenship or nationality, but about the ethnic group to which you feel you belong. If you feel you are descended from more than one group, please tick the one you feel you most belong to, or choose the ‘Any other ethnic group’ option.

Please tick:
C. Sex
D. Sexual Orientation
E. Religious Belief
F. Marriage or Civil Partnership
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