Social Work Bursary: Academic Year 2014/15 Application notes for students on postgraduate courses

Transcription

1 Social Work Brsary: Academic Year 2014/15 Application notes for stdents on postgradate corses These notes are for stdents who do not have a partner or any dependants. Please make sre yo complete the correct version of the form for yor circmstances - this form is only for stdents who do not have a partner, or anyone else who is financially dependent on them. All versions of the form are available at Changes to fnding explained The Department of Health have changed the way social work stdents are fnded from the 2013/14 academic year. All eligible postgradate stdents will be entitled to a Placement Travel Allowance (PTA) of (this amont will be paid pro-rata if yo are a part-time stdent), which can help yo towards the extra expenses incrred whilst yo are on yor placement. In addition yo may also be eligible for a brsary. There is now a cap on the nmber of postgradate stdents who can receive a brsary. Yor niversity/college will decide which stdents will be eligible to be assessed for a brsary so yo will not atomatically be entitled to one. Yo will initially be assessed for PTA only, and yo will be informed of any brsary entitlement once we have received notification from yor niversity/college that yo have been nominated for fnding. If yo received a brsary in the 2012/13 academic year and did not withdraw or defer from yor corse, yo will not fall into the new fnding arrangements. Completing the application Part 1 Yor details Please complete this section in BLOCK CAPITALS (inclding yor address) and tick all boxes appropriate to yor stats. This will help s hold the correct details for yo and contact yo if we need to. The names yo se here need to match the names yo give to yor niversity/college when yo register. Please provide details of all higher edcation qalifications yo hold. Application completion notes page 1 of 4

2 Part 2 Abot yor corse Please give s the exact name and level of the corse yo are stdying. Yo will not be eligible for the brsary if yo are on an employment based corse. These are generally when yor stdies are being spported by yor employer, inclding direct Open University corses. If yo are nsre of the name, level or type of corse yo are stdying, please ask yor niversity/college. If yo are repeating any modles of yor corse please tell s as we may need to contact yo and/or yor niversity/college regarding this. Part 3 Payment method Please give a bank accont that is in yor name (or a joint accont yo are named on). We will not pay any fnds into an accont that is not in yor name. Do not give the long nmber on yor card as we mst have the accont nmber and sort code. If yo are nsre what these are, please ask yor bank or bilding society. Part 4 Residency details A stdent mst satisfy the residency criteria before any brsary can be paid. Yo mst send original passports, residency permits, Home Office docments etc as we can not accept photocopies or scanned images. Yo mst also tell s if yo have lived otside of England anytime in the last three years leading p to the start of the first day of yor corse. This incldes living in Wales, Scotland or Northern Ireland. The fll residency criteria can be fond on or website at: If yo crrently have refgee stats or hmanitarian protection which has an expiry date then this mst be valid for the entire academic year (ntil 31 Agst 2015 for September starters or ntil 31 December 2015 for Janary starters) otherwise yo are not eligible for any fnding. If yo do not have a passport or driving licence, please contact s on and tell s which type of photo identity yo have and we will let yo know if it is acceptable. Part 5 Other grants, brsaries, retainers or spport Please tell s abot any other fnding yo have applied for or will be receiving while stdying. Please note: This does not inclde the Maintenance Grant which is linked to the social work brsary; we will ask yo abot this in part 7. Application completion notes page 2 of 4

3 Part 6 Employment details If yo are crrently working in the social care sector, please tick Yes and ask yor employer to compete 6.2. If yo begin working in the social care sector after the start of yor academic year, yo mst download and complete this part of the application form again ensring it is signed by yor employer and send it to s withot delay. Please ensre yo post the original form to s as we cannot accept photocopies, faxed or scanned copies of the form. Part 7 - Applying for the Maintenance Grant The Maintenance Grant is income assessed and takes into accont yor nearned net income for the 2014/15 academic year. Yo do not need to tell s abot any paid employment in this section bt we do need to know abot other income sch as taxable benefits, pensions, interest from investments or money earned from rent/lettings. Hint: We do not need to know abot non taxable benefits (sch as Child or Working Tax Credit, Child Benefit and Disability Living Allowance). If yo are nsre if the benefits yo receive are taxable, please ask the office that deals with yor claim. If yo receive money from rent, lettings etc, please provide evidence of the amont of rent received over the academic year and then provide evidence of charges yo pay relating to the property. Please note: Yor third instalment of brsary may be kept on hold ntil we verify yor nearned income and we are aware this may not be available ntil the end of yor academic year. We will notify yo of what evidence is reqired so yo can send it to s as soon as it becomes available. Part 8 Additional information Use this space to give s any additional information yo feel is relevant to yor application. If yo are repeating or have changed yor corse, please provide as mch information as yo can abot this. Part 9 Data Protection We will treat all information yo provide in line with the Data Protection Act Yo can nominate one person to speak to s on yor behalf; we call this third party athorisation. If yo wold like to nominate someone please provide their first and last name, fll date of birth and tell s the relationship between this person and yorself. We se this information as secrity qestions so please ensre these are completed correctly. Application completion notes page 3 of 4

4 Part 10 Applicant s declaration Please ensre yo read and nderstand the declaration as it provides important information regarding what to do if yo stop yor stdies for any reason. Once yo have read the declaration and yo are happy with all the information yo have spplied, please complete yor name and then sign and date the declaration. We cannot accept photocopies of the declaration page. Part 11 Posting yor application to Social Work Brsaries Please list all original docments which yo are sending with yor application. Yo shold send any valable docments to s throgh a secre postal method sch as Special Delivery. Yo shold enclose a self-addressed, pre-paid Special Delivery envelope for the retrn of yor docments. This will allow yo to track the retrn of yor docments once they leave s. If yo do not send a pre-paid Special Delivery envelope, yor docments will be retrned to yo by standard second class post. If yo are sending yor application by Special Delivery, make a note of yor Special Delivery reference nmber. Please send yor application to: Social Work Brsaries Bridge Hose 152 Pilgrim Street Newcastle Upon Tyne NE1 6SN Application completion notes page 4 of 4

5 Social Work Brsary: Academic Year 2014/15 Application form for stdents on postgradate corses This application form is for stdents who do not have a partner or any dependants. Important note: All eligible stdents will be entitled to a Placement Travel Allowance (PTA) of (this amont will be paid pro-rata if yo are a part-time stdent). In addition yo may also be eligible for a brsary if yo are nominated for fnding by yor niversity/college. 1 Yor details Official Use Box 1.1 Abot yo Are yo crrently receiving or have yo ever received a brsary (in fll or part) from the NHS Bsiness Services Athority (NHSBSA), General Social Care Concil (GSCC) or the Central Concil for Edcation and Training in Social Work (CCETSW)? No Yes Give yor brsary reference nmber Title Mr Mrs Other Ms Miss 7Yor brsary reference nmber begins with a 2 or 3. Please leave blank if nknown Srname or family name First name Other names 7 The names yo se here need to match the names yo give to yor niversity/college when yo register. Previos names Date of birth DD / MM / YYYY Residential address Town/city Postcode Daytime phone nmber Mobile phone nmber 7 This helps s contact yo more qickly and may 7 prevent processing delays. Application form page 1 of 17

6 1 Yor details contined 1.1 Abot yo contined Marital stats (tick one box) Single Separated Widowed Divorced Go to qestion 1.2 Cohabiting Married Civil partnership This form is not for se by stdents who have a partner. Please visit or website at to download the correct version of the application form. 1.2 Allowances for dependants Do yo want to apply for any of the following allowances for the academic year 2014/15: Adlt Dependants Allowance; Childcare Allowance; or Parents Learning Allowance? No Go to qestion 1.3 Yes This form is not for se by stdents who have dependants. Please visit or website at to download the correct version of the application form. 1.3 Qalifications Do yo have any degrees, diplomas or other qalifications at higher edcation level? No Yes Give details below Name of qalification Sbject Date awarded University/college / / 7 Do not inclde yor A Level qalifications. / / / / / / Application form page 2 of 17

7 2 Abot yor corse 2.1 Corse details Fll name of social work corse Is the corse employment based or college based? College based Employment based Is the corse fll-time or part-time? Fll-time Part-time How many years will yor corse last? Type of qalification yo will gain MA MSc Other Give details If yo are nsre, check with yor niversity/college 7 admissions department. 7 Placements are an essential component of yor stdy and do not necessarily mean yo are on an employment based corse (which is generally when yor stdies are being spported by yor employer, inclding direct Open University corses). If yo are nsre abot what type of corse yo are stdying, please ask yor niversity/college. 2.2 Details of where yo will be or are stdying Name of yor niversity/college Town/city 2.3 Stdy details Date yo intend to start or first started yor corse When do yo expect to complete yor corse? MM / YYYY MM / YYYY Year of corse yo are stdying in the academic year 2014/15 1st year 2nd year Other Give details 2.4 Repeat stdy Will yo need to complete any social work modles from a previos year in the academic year 2014/15? No Go to section 3 Don t know Inform s in writing of details when yo know go to section 3 Yes Go to section 3 - we may need to contact yo or yor niversity/college abot this Application form page 3 of 17

8 3 Payment method All payments are made by Banks Atomated Clearing System (BACS). Yo mst provide yor accont details by completing the BACS form below. We will not make payments to an accont that is not in yor name. The accont mst be in the UK, be able to accept payments by direct credit and be in the name of the brsary applicant. If yo are nsre of these details, please check with yor bank or bilding society. We are nable to pay the brsary into prepaid card acconts. Payment by BACS means yo receive yor money faster, provided that yo spply the correct information. Please take the time to complete this section careflly and write clearly, otherwise it may delay or prevent payments. 3.1 Payments of brsary received in previos academic years Have yo received payments of a Social Work Brsary for an academic year prior to 2014/15? No Go to qestion 3.3 Yes Go to qestion The accont we paid yor brsary to Do yo want yor brsary paid to a different accont to the last payment yo received from s? No Go to section 4 Yes Give details at part Details of yor UK accont Name accont held in This mst be in yor name Accont details Bank/bilding society name Branch address Town/city 7 If yo are nsre abot any of these details, check with yor bank or bilding society. If yo miss ot any details, yor payments may be delayed. Postcode Bank/bilding society sort code Accont nmber Roll or reference nmber Bilding society acconts only Application form page 4 of 17

9 4 Residency details Read part 4 in the instrction notes before completing this section. 4.1 The brsary in 2013/14 Did yo receive the brsary in the academic year 2013/14? No Go to qestion 4.4 Yes Go to qestion What is yor nationality? Please tick one box UK national Go to section 5 OR EU or Swiss national Go to qestion 4.3 OR Non UK national with the following stats Expiry date of stats DD / MM / YYYY Now go to section 5 OR No expiry date 4.3 Migrant or frontier worker stats Are yo claiming migrant or frontier worker stats? No Go to section 5 Yes Go to qestion Residency and nationality details What is yor nationality? What is yor contry of birth? Date yo came DD / MM / YYYY OR Not applicable to England Main reason yo came to England OR Not applicable Now go to section 4.5 Application form page 5 of 17

10 4 Residency details contined 4.5 Time spent living otside England Have yo ever lived otside England dring the three year period leading p to the start of the academic year 2014/15? No Go to section 4.6 Yes Give details below Contry yo lived in: From: / / To: / / Main reason yo lived there: Main reason yo retrned to England: Contry yo lived in: From: / / To: / / Main reason yo lived there: Main reason yo retrned to England: Contry yo lived in: From: / / To: / / Main reason yo lived there: Main reason yo retrned to England: If yo need more space to give details, se section 8 of this application form. Now go to section 4.6 Application form page 6 of 17

11 4 Residency details contined 4.6 Yor residency stats in the UK Tick the description of yor or yor relative s residency stats in the UK and provide the evidence we ask for. For the prposes of this application, yor relatives are: yor spose/civil partner; yor parents; yor step parents; and yor legal gardians. I am a UK national Send s yor original passport* OR I am a Eropean Union (EU) national Send s yor original passport* OR I or any of my relatives are Eropean Economic Area (EEA) or Swiss national migrant/frontier workers Please send s: applicant s original passport*; migrant/frontier worker s original passport*; evidence of three years employment history in the UK, dating back from 1 September immediately before the start of yor corse; and frontier worker s evidence of keeping a property in an EEA contry or Switzerland evidence of yor relationship to the migrant/frontier worker, for example, a birth/marriage certificate or adoption papers. OR I am a non UK national with the following stats: Expiry date of stats DD / MM / YYYY Please send s: yor original passport*; and OR No expiry date any original Home Office docmentation regarding yor or yor relative s stats in the UK and the date it was awarded, and the date it expires if applicable. 7 If yo are applying with refgee stats or hmanitarian protection and yor Home Office papers have an expiry date, they mst be valid for the entire academic year. *If yo do not have a passport, we can accept an original UK photo driving licence or original photo identity card as evidence. Application form page 7 of 17

12 5 Other grants, brsaries, retainers or spport Have yo applied for or are yo receiving any other grant, brsary, retainer or spport as well as the Social Work Brsary? No Yes Give details Name of organisation yo have applied to/are receiving fnding from 7 If yo need more space to give details, se section 8 of this application form. Name of the grant, brsary, retainer or other spport Dates of spport From DD / MM / YYYY If yo apply for or receive ANY other grant, brsary, retainer or spport after yo sbmit yor application, yo mst inform s in writing. Career development loans do not affect yor application for a brsary, bt if we confirm yor entitlement to a brsary, yo are obliged to let yor loan provider know. to DD / MM / YYYY 7 If yo are applying for or receiving a retainer, yo mst complete a 2014/15 brsary retainer declaration. Download a copy from or website ( and send it with yor application. Application form page 8 of 17

13 6 Employment details 6.1 Will yo be employed in the social care sector dring yor corse? No Go to section 7 Yes Yo mst ask yor line manager to complete the following declaration 6.2 Social care employer s declaration to be completed by yor employer Note to employers By completing this section yo are confirming that the brsary applicant is yor employee and is not receiving any of the following: sponsorship/spport; any paid time off to allow them to attend stdies; all or part of their tition fees; any practice learning opportnity with pay or any other financial spport; or any other form of spport in order to assist with their social work training. The person who completes this declaration mst be the applicant s line manager. If yo have any qestions please contact s on If yo are receiving a retainer only, yo mst complete a brsary retainer declaration. Download a copy from or website ( and send it with yor application. Name of manager Manager s job title Abot the applicant s social care employer Name of social care employer Address Town/city Postcode Contact phone nmber ( ) Abot the employee Employee s name Employee s job title Declaration I declare that I am the line manager of the applicant named above and that the applicant is not receiving any spport from the social care organisation shown above. I nderstand that if I give the NHS Bsiness Services Athority false, misleading or incomplete information, the applicant named above may be refsed financial spport or any crrent financial spport may be withdrawn reslting in an overpayment for the applicant and I may be prosected. I agree to be contacted by the NHS Bsiness Services Athority so they can verify the employment stats and any spport arrangements of the applicant named above. Signatre Date DD / MM / YYYY Application form page 9 of 17

14 7 Yor nearned income for the academic year 2014/15 Do yo want to apply for the maintenance grant in addition to the basic grant? (please refer to page 10 of the application instrctions) No Go to section 8 Yes Give details of the net nearned income (after Income Tax dedctions and National Insrance contribtions) yo expect to receive dring the academic year 2014/15. We will se this information to help s to work ot the level of spport yo are eligible for. Complete every box. If a qestion does not apply to yo, write None in the answer space. If yo do not know the exact amont, make an estimate and write Estimated next to the amont. Please send original evidence of nearned income of 1,000 or more. We may ask for evidence of any other amonts at a later date. Refer to the list, right, for details of evidence we will accept. Description of nearned income Net profit from property, lettings or rent Income from trsts Income from taxable pensions de to incapacity or disability Income from other taxable pensions Amont dring the the 2014/15 academic year Income from benefits List the type of benefit and give the amont expected - please see Part 7 of notes for more information Maintenance payments for yo, inclding volntary maintenance Maintenance payments for yor children, inclding volntary maintenance 7Acceptable evidence for section 7 (all evidence sbmitted mst be original): accontant s letter; tax self assessment form; benefits letter/statement; bank or bilding society statements of interest earned; dividend statements; pension statements; NHSBSA confirmation of benefits; Child Spport Agency letter; maintenance cort order; confirmation of volntary maintenance letter. 7Send a copy of the cort 7order or other evidence Other nearned income List the type of nearned income, sch as bilding society interest, investments or sponsorship, and give the amont expected Total nearned income Add p all the nearned income yo have listed Application form page 10 of 17

15 8 Additional information Use this space if yo need to contine any of yor answers or if there have been any changes which may affect yor brsary application sch as changes to yor corse or the need to repeat all/part of a stdy year. 7If yo need to contine any of yor answers, please indicate clearly which qestions yo are contining. Application form page 11 of 17

16 9 Data Protection Data Protection Act 1998 The NHSBSA will se the information that yo have provided for the processing of yor application and for the prevention and detection of frad. We may contact yo to discss yor application and or qality of service to yo by any methods yo have provided. Yor personal data will be deleted from or systems and files no later than seven years after the month in which yor application is processed. We will not disclose yor personal data to any third party nless they have a lawfl right obliging s to do so other than: niversities/colleges; local athorities; organisations from which yo receive benefits, brsaries, grants or spport; the Home Office; Stdent Finance England; the Stdent Loans Company; and HM Revene & Cstoms. We will not transfer yor personal data otside the Eropean Economic Area. Third party athorisation De to data protection, we are only able to discss yor brsary and other personal details with yo and the organisations listed above. If yo wold like to athorise another person, sch as a parent, to discss yor brsary, please fill in their details below. We will verify their details if the person contacts s. Yo mst sign the applicant s declaration in order for the third party athorisation to take effect and to indicate that yo have soght the person s permission for s to contact them. Third party s first name Third party s last name Third party s date of birth DD / MM / YYYY Relationship between yo and the third party 7 This will be sed as a secrity qestion. Application form page 12 of 17

17 10 Applicant s declaration Read this declaration careflly before signing it. If yo choose not to sign it, we will be nable to process yor application for a Social Work Brsary. I declare that: A B C D E F I will be/am taking a postgradate social work corse which is eligible for the Social Work Brsary. I have read and nderstood the application instrctions in fll. By signing this declaration I agree to the following conditions: I will spply any additional information which might reasonably be reqired by the NHSBSA to verify the information I have given on this form. I will inform the NHSBSA immediately in writing of any change in circmstances that might affect my entitlement to financial spport or the NHSBSA s records relating to me. This incldes, bt is not limited to: withdrawing, sspending, deferring or interrpting the corse temporarily or permanently for any reason, regardless of whether I intend to retrn; changing my stdy pattern from fll-time to part-time, or vice versa; being nable to attend the corse for any reason where it exceeds 15 calendar days in total; changing the accont I want my payments made to; changing address; or gaining spport from a pblicly fnded body (exclding any of the following: Stdent Finance England, Access to Learning Fnd, government benefit agencies and brsaries from my niversity/college) or my social care employer. Failre to inform the NHSBSA may prohibit frther payments and may constitte frad by failing to disclose information which may reslt in criminal prosection. I accept that the NHSBSA will immediately terminate or sspend my fnding if: I withdraw, sspend, defer or interrpt the corse temporarily or permanently for any reason, regardless of whether I intend to retrn; I am nable to attend the corse for any reason where it exceeds 15 calendar days in total; I take a year or a term ot from stdy; the NHSBSA determines at its absolte discretion that it is reasonable for it to do so; I gain spport from a pblicly fnded body (exclding any of the following: Stdent Finance England, Access to Learning Fnd, government benefit agencies and brsaries from my niversity/college) or my social care employer: or The NHSBSA determines at its absolte discretion that I am no longer entitled to financial spport. I will pay back to the NHSBSA within 30 days of receiving notification any excess payment, all fees and any other charges in the event of the following circmstances: changing my stdy pattern from fll-time to part-time; withdrawing, sspending, deferring or interrpting the corse temporarily or permanently for any reason, regardless of whether I intend to retrn; Application form page 13 of 17

18 10 Applicant s declaration contined being nable to attend the corse for any reason where it exceeds 15 calendar days in total; being overpaid becase I have failed to inform the NHSBSA of a change in my circmstances; an NHSBSA administrative error; where the NHSBSA at its absolte discretion determines that I have been given financial spport to which I am not entitled, irrespective of any decision made by Stdent Finance England; or gaining spport from a pblicly fnded body (exclding Stdent Finance England, Access to Learning Fnd, government benefit agencies and brsaries from my niversity/college) or my social care employer. Shold I fail to make fll repayment of any amont de or agree an acceptable repayment plan with Social Work Brsaries, the debt may be passed to a debt collection agency. I agree that I will be charged for any additional recovery costs which will be added to the balance otstanding on referral. G I nderstand and accept that the NHSBSA will make recovery of incorrect or fradlent payments and that sspected fradlent applications will be referred for frther investigation to a Conter Frad Specialist, which may reslt in criminal prosection. I nderstand and accept that if I fail to give sfficient notice of any change to my bank or bilding society accont details, or provide incorrect details, the NHSBSA cannot take responsibility for payments made to an incorrect accont, delayed payments or non payment of the brsary. I nderstand and accept that the terms and conditions (inclding rates) of the brsary may change at any time withot notice, and that the scheme is sbject to contined government fnding, which may cease at any time withot notice. I declare that the information I have given on this form is tre, complete and accrate. I nderstand and accept that if I provide the NHSBSA with false or misleading information, financial spport may be refsed or withdrawn and I may be liable to prosection and/or civil proceedings. Applicant s fll name Applicant s signatre Date DD / MM / YYYY Application form page 14 of 17

19 11 Posting yor application to Social Work Brsaries Docment list List all of the original docments yo are sending with yor application and fasten yor docments to this page. If yo are nable to provide the reqired docmentary evidence, yo can complete and sbmit the additional forms that are available from or website at We will se this list to check that we have received all of yor docments. For official se only Yor docments We will retrn any docments yo have posted to s within for weeks of receiving them. We recommend that yo inclde a pre-paid, self-addressed, Special Delivery envelope with yor application form for s to retrn yor original docments. This will allow yo to track the retrn of yor docments once they leave s. If yo do not, we will retrn all original docments by second class post. The NHSBSA cannot take responsibility for items lost in the post. Application form page 15 of 17

20 11 Posting yor application to Social Work Brsaries contined Keep a photocopy of all docments sent for yor own records. The NHSBSA cannot take responsibility for applications and evidence lost in the post. Attach a pre-paid, self-addressed Special Delivery envelope if yo are sending spporting docments to s, so we can retrn them to yo secrely and yo can track them once they leave s. If yo do not provide this we will retrn yor docments by second class post. Pay the correct postage and write yor name and address on the back of the envelope to avoid yor mail going astray. Post If yo are sending yor application by Special Delivery, make a note of yor Special Delivery reference nmber. Post this form by Special Delivery to garantee it is delivered to: Social Work Brsaries Bridge Hose 152 Pilgrim Street Newcastle Upon Tyne NE1 6SN Application form page 16 of 17

21 12 Checklist Use the checklist below to make sre that yor application is complete. Have yo read the application instrctions that accompany this application form? Yes No Have yo kept a copy of yor application form and the instrctions for ftre reference? Yes No Have yo answered all of the qestions in each part of this application that apply to yo? Yes No Have yo stapled or secrely clipped all original evidence we have asked for? Yes No Have yo inclded a pre-paid, self-addressed, Special Delivery envelope for the retrn of yor original docments? (Please note that yor docments will be retrned by second class post if yo do not provide this) Yes No Have yo signed and dated the applicant s declaration on page 14? Yes No Have yo written down all the docments yo are sending with this application in the space provided on page 15? Yes No If applicable, have yo inclded a Disabled Stdent Allowance application? Please note - yo need to apply each year for DSA fnding Yes No Not applicable Are yo sending yor application by Special Delivery post? Yes Make a note of yor Special Delivery reference nmber No Application form page 17 of 17

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23 Social Work Brsary Eqal Opportnities Qestionnaire NHS Bsiness Services Athority (NHSBSA) Policy The NHSBSA is committed to eqality of opportnity and to policies and procedres which ensre no applicant receives less or more favorable treatment on the gronds of race, disability, gender, age, religion or belief and sexal orientation. Please provide s with some information abot yorself. It is not complsory to do so, bt yo can be assred that all the information yo do provide will be kept completely confidential. No identifiable information abot yo will be passed on to any other bodies, members of the pblic or press. 1) Which niversity/college are yo stdying at? 2) Which corse are yo ndertaking? 6) Which age grop applies to yo? Tick one box only years years years 3) Which academic year is this application for? Tick one box only. 2014/ /14 Other, please state below 4) Do yo wish to declare information abot yor stats? NB: We will only se this information to monitor the diversity of applicants. It will not be linked to or stored against yor personal details and will not be sed for any other prpose. Yes Go to Qestion 5 No Go to Qestion 12 5) What is yor gender? Tick one box only. Male Female years years 65 years and over 7) What is yor ethnic grop? Tick one box only. A White British Irish Any other backgrond, write below B Asian or Asian British Indian Pakistani Bangladeshi Any other Asian backgrond, write below Transgender/transsexal EOQv5 Page 1 of 2

24 C Mixed White and Black Caribbean White and Black African White and Asian Any other Mixed backgrond, write below D Black or Black British Caribbean African Any other Black backgrond, write below E Chinese or other ethnic grop Chinese Any other, write below 10a) Are yo a disabled person as defined by the Eqality Act 2010? Tick one box only. Yes No The Eqality Act 2010 defines a disabled person as someone who has a physical or mental impairment that has a sbstantial and long-term adverse effect on his or her ability to carry ot normal day to day activities. 10b) If yes, please tick all which apply. Physical impairment Sensory impairment Mental health problem Learning disability/difficlty Long standing illness 8) Which of the following best describes yor sexal orientation? Tick one box only. Lesbian Gay Bisexal Other 11) Please enter yor occpation before the start of yor corse. Heterosexal 9) What is yor religion or belief? Tick one box only. (Christianity incldes Chrch of Wales, Catholic, Protestant and all other Christian denominations.) No religion Bddhism Christianity Please enter the occpation of the main earner of yor hosehold. 12) Send this form to s with yor completed brsary application. Hindism Islam Jainism Jdaism Sikhism Other, write below EOQv5 Page 2 of 2