Nye Bevan and VIVA Equality and Diversity Questionnaire Nye Bevan and VIVA Equality and Diversity Questionnaire Your Job Role* Your Age Range*21-3031-4041-5051-6061-70Your Regional Location* Your Gender*MaleFemaleDont Wish To DiscloseDo You Have Any Disabilities*YesNoDont Wish To DiscloseDisability ListVisual impairmentHearing impairmentDisability affecting mobilityOther physical disabilityOther medical condition (for example epilepsy,Emotional/behavioural difficultiesMental health difficultyTemporary disability after illness (for example post-Profound complex disabilitiesAsperger’s syndromeOtherEthnic OriginWhite BritishWhite IrishWhite, any other backgroundMixed – Black/Black British CaribbeanMixed – Black/Black British AfricanMixed – White and AsianMixed, any other backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian, any other backgroundBlack/Black British – CaribbeanBlack/Black British – AfricanBlack/Black British – Any other backgroundOther Ethnic Group – ChineseOther Ethnic GroupDo Not Wish To DiscloseA bit of background about your experience with the NHS* Phone Number*