Ethnicity and Language Questionnaire

In England and Wales, there are 18 ethnic groups recommended for use by the government when asking for someone’s ethnicity. These are grouped into 5 ethnic groups, each with an ‘Any other’ option where people can write in their ethnicity using their own words. These groups were used in the 2011 Census of England and Wales.

Ethnicity and Language Questionnaire

Patient Details

Please use date format DD/MM/YYYY
Any responses will be sent to this email address

Ethnicity Data

Please select your ethnic background from the options below: *
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Further Questions

Do you require an interpreter?
Please use date format DD/MM/YYYY