Section 75a Equal Opportunities Form Breastfeeding Peer Support (MOHAL) 24-25

1. What is your sex?

(Required) Female Male Other

if other please specify

2. Is the gender you identify with the same as your sex registered at birth?

(Required) Yes No Prefer not to say

3. What is your country of birth?

(Required) Northern Ireland England Republic of Ireland Scotland Wales Prefer not to say Elsewhere

If elsewhere, please specify

4. What is your ethnic group?

(Required) White Chinese Irish Traveller Filipino Roma Indian Black African Black Other Mixed Ethnic group Other Ethnic group Prefer not to say

5. In accordance with the Disability Discrimination Act 1995, a disability is defined as a physical or mental impairment which has a substantial and long-term effect on a person's ability to carry out normal day-to-day activities. Under this definition, do you consider yourself as having a disability? If yes, please select all that apply.

(Required) Yes No Prefer not to say

Physical Impairment, eg. difficulty using arms or requiring a wheelchair or crutches Sensory Impairment, such as blind/ visual impairment or deaf/ hearing impairment Mental Health condition, eg. depression or schizophrenia Autism Spectrum Disorder; Dyslexia; Cognitive Impairment; Learning disability Long standing illness; such as cancer, HIV, diabetes, chronic heart disease or epilepsy Other (please specify)

6. How would you describe your sexual orientation?

(Required) Heterosexual Bisexual Lesbian Gay Prefer not to say Other

If other please specify

7. How would you describe your caring responsibilities? (Tick all that apply)

(Required) Child(ren) under 18 An older person A person with a disability None Prefer not to say

8. Please indicate your religion:

(Required) Buddhist Catholic Hindu Jewish Muslim Protestant Sikh None Prefer not to say Other, please specify

9. Please indicate your marital status:

(Required) Married Cohabiting Divorced/ Dissolved Civil Partnership Separated Single Widowed Prefer not to say Other

If other please specify

10. How would you describe your political opinion?

(Required) Broadly Nationalist Broadly Unionist Prefer not to say Other

If other please specify

11. What age were you on your last birthday?

(Required) 17-24 25-34 35-44 45-54 55-64 75+

12. In which hospital did you deliver your baby/babies?

(Required) Craigavon Area Hospital Daisy Hill Hospital

Section 75a Equal Opportunities Form Breastfeeding Peer Support (MOHAL) 24-25

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Equality and Diversity