Diversity Questionnaire

Gather feedback and experiences from service users about fairness, accessibility, and treatment received across local health services.

Use this template

Please provide more details about your answer.

In your opinion, what are the most important priorities for equality and diversity within your local health services?

What can we do to improve our communication with you and others in your community?

Have you encountered any obstacles in using or accessing our services?

Yes No

Was it related to any of the following reasons?

Language barrier Waiting times Physical accessibility Cultural differences Lack of information

Please indicate your gender.

Male Female Non-binary Prefer not to say

Is this the gender you were assigned at birth?

Yes No

Do you consider yourself to have a disability or a long-term illness?

Yes No

Please indicate your age.

Please indicate your sexual orientation.

Please describe your religious or philosophical beliefs.

Do you have any other thoughts or suggestions?

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