Discrimination Law Enquiry Form (DEF001)

Title *

Other title: *

First Name *

Family Name (Last, Surname) *

Date of Birth *

National Insurance Number

Address *

I don't have a home address.

If you have an address of a trusted friend or family member where you can be contacted, please detail it below. Please note the following field is not required, but please provide an address if at all possible.

C/O Address

Main Telephone Number *

I'm happy for you to leave a message on my main telephone number

Secondary Telephone Number

I'm happy for you to leave a message on my secondary telephone number

Email *

I don't have an email address.

What is your preferred contact method? *

Is an interpreter needed? *

Language *

Is there any special assistance you may require?For example, "I am partially deaf and need you to speak clearly"

Where did you hear about the Suffolk Law Centre? *

Other *

Other agency: *Please provide the name of the agency/organisation.

Have you received help from us before? *For example, an appointment.

Do you currently have a Solicitor or Barrister representing you in this matter? *

Are you a member of a Union? *

Do you have Legal Expenses Insurance? *

Do you have household insurance that includes legal protection? *

Does the complaint relate to employment? *

Does the complaint relate to goods and services (including housing, public services, education or transport)? *

Does the complaint relate to a police complaint? *

Do you know the names or policing numbers of the officers involved? *

Please specify the names or policing numbers of the officers involved: *

Have you been arrested in relation to this act? *

Have you retained the body worn video in relation to this act? *You only have 6 weeks to request this information before it is deleted.

Name of the person/organisation you are in dispute with/opposition *

Other (please enter): *

Name of the person/organisation you are in dispute with/opposition (if known)

Job title of person who has done discriminatory or harassing act (if known)E.g. Joe Bloggs - Office Manager

Address of the person/organisation you are in dispute with/opposition. (if known)

It is important that we have these details for professional conduct reasons, please note that it is kept confidential.

I don't know the address of the other party.

Date of the act(s) complained of *

Day

Month

Year

If there are multiple dates, please note this in the text box below.

What is the act(s) complained of? *How do you feel you have been discriminated against? Please include names, job titles and dates.

Equality Monitoring Form

Please now complete this Equality Monitoring Form.

We need this information to ensure that our policies, practices and procedures promote equality of opportunity. It is also a requirement of our funding grants and the Legal Aid Agency.

All information provided will be kept confidentially in accordance with the General Data Protection Regulation (GDPR). We hold your information on our Case Management System. For Legal Aid matters, we are required to share your personal equality data. For funding grants, this data is anonymised for reporting purposes.

Please choose your local authority *

Other local authority: *

Sex *

Is your current gender presentation the same as the one observed at birth? *

How would you describe your sexuality? *

Personal status *

What age group do you belong to? *

Do you consider yourself to have a disability? *Under the Equality Act 2010 a disability is defined as a ‘physical or mental impairment which has, or had a substantial and long term adverse effect on a person’s ability to carry out normal day to day activities’.

Please indicate which ethnic group you belong to *

Country of Birth *

Please indicate which religion you consider yourself to belong to *

Other religion: *

Are you? *

What is your average monthly income (£) *

Salary Calculation (Average Monthly Income x12)

Are you in receipt of any benefits? *

Please write which benefit(s) you receive: *

Data Protection Statement

The information in this Equality Monitoring Form is important to us because it allows us to monitor our compliance with the law and to ensure that our services are reaching a diverse group of service users. We are also asked, from time to time, to report it, in a anonymised form, to our funders. Any information you provide will be treated with confidence and kept confidential. Because of the nature of this information, we need your consent before we can collect and use it.

You have the right to be told what data we hold about you (though you are likely to have provided us with that data) and to have it corrected if it is wrong. You may have other rights under the data protection legislation and you can out more about these rights from the Information Commissioner’s Office at www.ico.org.uk. For details of our full Privacy Notice, please visit https://suffolklawcentre.org.uk/about-us/privacy-notice/

I consent to you using this information for the purpose of equality and diversity monitoring. I understand that I can withdraw my consent at any time.

Yes, I agree.

Please enter your full name in place of a signature. *