Tackling Discrimination in the East Booking Form

Title *

Other title: *

Name *

First Name

Family Name

Date of Birth *//

National Insurance Number

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Main Telephone Number *

Leave message on main telephone number?

I'm happy for you to leave a message on my main telephone number

Secondary Telephone Number

Leave message on secondary telephone number?

I'm happy for you to leave a message on my secondary telephone number

Email

What is your preferred contact method? *

Is an interpreter needed? *

Language *

Where did you hear about the Suffolk Law Centre? *

Other: *

Please identify which strand of discrimination apply: *

Employment Status *

Does the complaint relate to employment? *

Does the complaint relate to good and services (including housing, public services, education or transport)? *

Does the complaint relate to a police complaint? *

Name of the person/organisation you are in dispute with/opposition *

Address of the person/organisation you are in dispute with/opposition *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

It is important that we have these details for professional conduct reasons, please note that it is kept confidential.

Date of the act(s) complained of *

What is the act(s) complained of? *

Please include names, job titles and dates.

Name of person who has done discriminatory or harassing act (if known) and job title (if known)

First Name

Family Name

Equality Monitoring Form (Discrimination Matters)

We collect and monitor data on equality to ensure that our policies, practices and procedures promote equality of opportunity. It is also a requirement of our funding grants.

All information provided will be kept confidentially in accordance with the General Data Protection Regulation (GDPR). We hold the individual’s information on our Case Management System, but then anonymise the data for reporting purposes.

Please choose your local authority *

Other local authority: *

Sex *

Is your current gender presentation the same as the one observed at birth? *

How would you describe your sexuality? *

Personal status *

What age group do you belong to? *

Do you consider yourself to have a disability? *

Under the Equality Act 2010 a disability is defined as a ‘physical or mental impairment which has, or had a substantial and long term adverse effect on a person’s ability to carry out normal day to day activities’.

Please identify your disability *

Other disability *

Please indicate which ethnic group you belong to *

Other ethnic group *

Country of Birth

Please indicate which religion you consider yourself to belong to *

Other religion *

Are you? *

What is your average monthly income (£) *

Are you in receipt of any benefits? *

Data Protection Statement

The information in this Equality Monitoring Form is important to us because it allows us to monitor our compliance with the law and to ensure that our services are reaching a diverse group of service users. We are also asked, from time to time, to report it, in a anonymised form, to our funders. Any information you provide will be treated with confidence and kept confidential. Because of the nature of this information, we need your consent before we can collect and use it.

You have the right to be told what data we hold about you (though you are likely to have provided us with that data) and to have it corrected if it is wrong. You may have other rights under the data protection legislation and you can out more about these rights from the Information Commissioner’s Office at www.ico.org.uk. For details of our full Privacy Notice, please visit http://www.iscre.org.uk/legal-services/privacy-notice/

I consent to you using this information for the purpose of equality and diversity monitoring. I understand that I can withdraw my consent at any time.

Please tick this box to confirm that you agree to us hold this information *

Yes, I agree

Signature

Equality Monitoring Form (Discrimination Matters)

Data Protection Statement

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