Complaints/feedback

*Title: Mr Mrs Miss Ms Dr

*First name:

*Last name:

*Email:

*House number / name:

*Street:

*Area:

*Town:

*Postcode:

If you are making this complaint / compliment for someone else, please give their name

Their first name:

Their last name:

*Please tell us what you complaint / compliment is:
Complaint / Compliment

*If you are making a complaint, what solution do you believe would be fair to all parties?
Solution

Equality monitoring

To help us make sure that no one is treated unfairly because of their sex, race or disability, please tick the details that apply to you:

What is your ethnic group?

White

British Irish Any otherwhite background

Please write in:

Mixed

White and Black Caribbean White and Black African
White and Asian Any other mixed background

Please write in:

Asian or Asian British

Indian Pakistani
Bangladeshi Any other Asian background

Please write in:

Black or Black British

Caribbean African Other

Please write in:

Chinese or other ethnic group

Chinese Other

Please write in:

Please tell us your age:

16 to 24 25 to 34
35 to 44 45 to 54
55 to 59 60 to 64
65 to 74 74 +

Gender – are you?

Male Female

Do you have a long-standing illness, disability or infirmity?

‘Long standing’ means anything that has troubled you over a period of time or that is likely to affect you over a period of time.

Yes No Don't know

Text in image: (cAse SeNSItivE!)