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Tuesday 25 April 2017
Derbyshire Healthcare NHS Foundation Trust
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Data Collection Form

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Ethnic Data Collection
The Race Relations Amendment Act 2000, the Disability Discrimination Act 1995, the Disability Discrimination Act 2005 and the Gender Equality Duty (GED) of April 2007, requires us to make sure all our policies, practices, services and functions are fair and none of them create barriers for particular racial groups or disabled people. 

    

We would therefore be grateful if you would select one of the appropriate boxes below:

I describe my ethnic category as: »

Declaration

I declare that the information I have given on this form is correct to the best of my knowledge.

        

If you have any queries or need help with completing your application please do not hesitate to contact us either by telephone or by email.

    

Direct dial: 01332 623760 

Switchboard: 01332 623700 ext 33760

Once completed you can either email your form attaching any relevant documents or post to us: e-mail: dhcft.accesstoahealthrecord@nhs.net

Postal address: 

Access to a Health Record

IM&T and Records

Kingsway House East

Kingsway site

Derby

DE22 3LZ