Disability Confident Apply to be a Disability Confident Leader

Complete this form to:
- confirm you’ve completed the Disability Confident Employer self-assessment
- tell us who’s validated your self-assessment
- record the details of the activities you’re taking to become a Disability Confident Leader
- confirm you’re taking action to record and report on disability, mental health and wellbeing in the work place
- confirm the activities you're doing to get the right people for your business and keep and develop disabled people
About your business
Disability Confident reference number * REQUIRED
you will need this number to confirm you signed-up
Business name * REQUIRED
Contact name * REQUIRED
Business email * REQUIRED
Business phone * REQUIRED
Enter the approximate number of UK employees * REQUIRED
Please enter a number less than or equal to 999999.

Confirmation of your self-assessment

Complete this form to:
- confirm your Disability Confident Employer self-assessment has been validated
- tell us who's validated it
- record the details of the activities you’re taking to become a Disability Confident Leader
Validating organisation name * REQUIRED
Contact name at validating organisation * REQUIRED
Validator email * REQUIRED
Validator phone * REQUIRED
Date of Validation * REQUIRED
For example, 15 9 2016

DD
MM
YYYY
How is your business showing leadership? * REQUIRED
Please provide details of the activities you have taken, or are taking, in support of being a Disability Confident leader.

Confirmation of reporting on disability, mental health and wellbeing

To become a Disability Leader, you must confirm you are:
- employing disabled people
- recording and reporting information on disability, mental health and wellbeing
For more information read the Disability Confident Leader pack or contact the Disability Confident team.
Do you employ disabled people? * REQUIRED
- Yes
- No
Are you recording and reporting information on disability, mental health and wellbeing? * REQUIRED
- Yes
- No
Are you publicly reporting the percentage of individuals who consider themselves as being disabled, or will do so within the next 12 months? * REQUIRED
- Yes
- No

Apply to be a Disability Confident Leader