DIVERSITY SURVEY
FOR VOLUNTEERS IN CHEEVERSTOWN
The Cheeverstown’s volunteer programme aims to provide equal opportunities and fair treatment
for all volunteers. We would like you to complete this form in order to help us understand our
volunteers and to provide a better service for everyone involved in Cheeverstown. The
information will be used to provide an overall profile and analysis of our volunteer base. It will
help us to identify and target people not presently fully represented within our volunteer profile.
We would appreciate if you could complete the form below and email or post it to the address at
the bottom. The information below is anonymous and will not be stored with any identifying
information about you. All details are held in accordance with the Data Protection (Amendment)
Act 2003
If you would like this form in an alternative format or have any queries, please contact Gerry
O’Connor.
Please tick (×) your answers.
GENDER
☐Female
☐ Male
AGE
Please choose your age group.
☐ 18-25
☐ 26-35
☐ 36-45
☐ 46-55
☐ 55-65
☐ 65+
☐ Rather not say
ETHNICITY
What is your ethnic origin?
The ethnicity is distinct from nationality and the categories below are in alphabetical order.
Asian
Black
Mixed
☐ Chinese
☐ Indian
☐ Any other Asian
background (please name)
☐ African
☐ White and Asian
☐ Caribbean
☐ White and Black
☐ Any other Black background ☐ Any other mixed
(please name)
background (please name)
White
Other ethnic group
☐ White Irish
☐ Any other ethnic group
(please name)
☐ White Irish Traveller
☐ Any other white background
(please name)
1
☐ I don’t know
☐ Rather not say
RELIGION
Which group below do you most identify with?
☐ Baha’i
☐ Buddhist
☐ Catholic
☐ Church of Ireland
☐ Hindu
☐ Jain
☐ Jewish
☐ Muslim
☐ Sikh
☐ Other (please name)
☐ No religion
☐ Rather not say
DISABILITY
The Disability Act (Government of Ireland, 2005) defines disability as 'a substantial restriction in
the capacity of the person to carry on a profession, business or occupation in the Irish State or to
participate in social or cultural life in the Irish State by reason of an enduring physical, sensory,
mental health or intellectual impairment’ (pg. 6).
‘The definition of disability contains the concept 'substantial restriction' and this is seen as a
restriction which:- (a) is permanent or likely to be permanent, results in a significant difficulty in
communication, learning or mobility or in significantly disordered cognitive processes, and (b)
gives rise to the need for services to be provided continually to the person whether or not a child
or, if the person is a child, to the need for services to be provided early in life to ameliorate the
disability’
Do you consider yourself to have a disability according to the above definition?
☐ Yes
☐ No
☐ Rather not say
Today’s date:
Please return your completed form to:
goconnor@cheeverstown.ie
or
Gerry O’Connor, Cheeverstown, FREEPOST Templeogue, Kilvare, Dublin 6w.
THANK YOU!
2