You do not have to complete the following section of the form. However, your answers will help us to monitor whether we are providing improving services to all of our customers. All of the information that you provide will be kept in strict confidence in accordance with the Data Protection Act 1998 and the information will only be used by Chevin Housing Association and those partners directly involved in providing housing management and services to you.

Section One of the Disability Discrimination Act defines disability as a physical or mental impairment, which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities.

Using the above definition, do you consider yourself to have a disability?

If yes, please give details: