Premises Questionnaire

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All questions marked with a * are mandatory

Questions about you
Please select the option which applies to you:
Which transport options are currently available to you for travelling to the practice?:
Tick all that apply
What is important to you when accessing or registering for GP services?:
Questions about our proposal to move Warders Medical Centre to a new site
Do you have any further comments that you have regarding the permanent move of Warders Medical Centre?:
Equality and Diversity Monitoring Form - Service Users (Public/Patients)

Why we are asking you to complete this form

The information that we are asking you to provide in this form links to our compliance with the Equality Act 2010, Public Sector Duties (2011), where we give due regard to the need to:

  • Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.
  • Advance equality of opportunity between people who share a protected characteristic and those who do not.
  • Foster good relations between people who share a protected characteristic and those who do not.

The aims and commitments set out in our equality policy enable us to carry out these duties appropriately.  Our commitment to collect and monitor equality data about our service users provides us with key information that helps us to identify gaps and/or discrepancies in our practices. 

You are not obliged to answer these questions, and we understand that you may find some of this information personal and sensitive in nature.  Please note, however, by gathering this data it helps us to understand the diversity of the people we serve and enables us to ensure that we are doing the utmost to support all our service users in a fair and equitable way. 

Data protection

The information you provide is anonymous and will not be stored with any identifying information about you. We may use anonymised statistics and data provided by you collectively to identify trends and inform discussions about how to improve our practices. No information will be published or used in any way which allows any individual to be identified. All details are held in accordance with the Data Protection Act 1998.

If you would like this information in an alternative format, or would like help in completing the form, please contact us.

Equality Monitoring Information

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months (include any problems related to old age)?:
Please indicate your disability or disabilities:
Tick all that apply
Do you have any specific needs and/or requirements?:
Gender reassignment: Have you gone through any part of a process, or do you intend to (including thoughts or actions) to bring your physical sex appearance, and/or your gender role, more in line with your gender identity?:
This could include changing your name, your appearance and the way you dress, taking hormones or having gender confirming surgery
Are you pregnant or have given birth in the last 26 weeks?:
Caring Responsibilities: Do you look after, or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health / disability, or problems related to old age?:
Tick all caring responsibilities that apply:
Amount of time spent in relation to caring duties:

Thank you for taking the time to complete this questionnaire.

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