Equality and Diversity Form

In line with other NHS organisations, Coventry and Rugby Clinical Commissioning Group collects information about the ethnicity, age, gender, disability and religion/belief of complainants and patients. This information can help us to plan and commission NHS services to meet the needs of the community and to ensure that everyone has equal access to healthcare.

Please note we are not asking about your nationality, but the ethnic group to which you feel you belong to.

All information we receive will be used and treated with the strictest confidence. Should you wish to include your name, please be assured that any information will be used in an anonymous format. The completion of this form is entirely voluntary but your information will help us plan and commission better NHS services and health care.

We would like to assure you that the level of care and treatment you receive from NHS Services will not be affected by your decision to complete this form.

Please complete the form below by ticking the boxes that you feel are appropriate to you.

It would be helpful to us if you would supply the following details. This will help us to ensure that no particular group is being disadvantaged. THIS INFORMATION WILL BE HELD IN CONFIDENCE AND WILL NOT BE ATTRIBUTED TO ANY INDIVIDUAL

Equality and Diversity Form
Equality Act 2010 Protected Characteristics

Please provide the following information about the patient

If the answer is yes, please state the impairment which applies to the patient. People may experience more than one type of impairment, in which case you may indicate ore that one. If none of the categories apply, please mark ‘other'.

Thank you for helping us by completing this form.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the CCG and is accessed over a secure connection by nominated members. Our CCG has a strict confidentiality policy.

This information is not shared with any third party organisations.

On our website:

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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