OFFICIAL SENSITIVE PERSONAL RN Version Nov 22 2

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Royal Navy Family Origins Questionnaire

UNIQUE SURNAME GIVEN NAME DATE OF
NUMBER BIRTH

This questionnaire includes questions about your family’s origin and will help us to work out
your genetic heritage. Your answers will help us decide whether you have
Sickle Cell Trait (SCT), a condition that affects your blood and may lead to problems during
intense exercise. Depending on your answers we might invite you to undertake a
confirmatory blood test.

SCT is most common in people with African and Caribbean family origins, but also occurs in
people with Mediterranean, Middle-Eastern and Indian heritage.

We need to understand where your family is from originally; this might be different from
where you live now, where you were born, or your nationality.

What do you need to do?

Please answer this questionnaire as best you can. This form should take no more than 5
minutes to complete.

You may need to ask your family for help with some of the answers.

By completing this form, you are consenting to the Royal Navy and its contracted medical
assessors (Capita) requesting and storing this information.

If you decide not to complete these questions or have a blood test if suggested your
application may be delayed.

Please check the box below if you do not consent to completing this form and return it with
your RNMQ and Opticians Report as directed.

I DO NOT CONSENT TO COMPLETING THIS FORM

How to complete the questions

There are 2 sets of questions - the first is about your family origin and the second about
bone marrow transplants.

1. Your family origin.

Please check the correct boxes in the table.

Make sure that you answer for both birth parents and all four grandparents
even if deceased.
There should be at least one box checked in each column.
If a family member has mixed heritage, you can check more than one box.
If you are adopted, or do not know about your family’s origin, please check
“Don’t Know or Adopted’.

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Please answer the following questions

Have you ever been tested for SCT Yes No

If Yes the result is Positive Negative Unknown

Please check one box that applies to each of your family members for each column.

Family Origin Biological Biological Maternal Maternal Paternal Paternal

mother father grandmother grandfather grandmother grandfather
(birth mum) (birth dad) (mum’s mum) (mum’s dad) (dad’s mum) (dad’s dad)
A:Black – African or African-
Caribbean
(to include Africa, except North
Africa, any other African family
origins)
B: South Asian Nepal Tharu
(caste) and Terai region only
Indian or African Indian
Pakistan, Bangladesh, Sri Lanka
Afghanistan, Kyrgyzstan,
Turkmenistan, Tajikistan,
Uzbekistan,
Kazakhstan.
C:Southeast Asian
Nepal except Tharu (caste) and
Terai region
China including Hong Kong, Taiwan
Singapore, Thailand, Indonesia
Malaysia, Vietnam, Philippines
Cambodia, Laos, Myanmar
Any other Asian family origins
Any Melanesian/Polynesian country
(includes Fiji, Tonga)
D: Other
Non-European
(to include North Africa, South /
Central America, Middle East,
Saudi Arabia, Iran, Any other non-
European family origins)
E: White -
Southern and Other European
(to include Sardinia, Greece,
Turkey, Cyprus, Italy, Portugal,
Spain, Albania, Czech Republic,
Poland, Romania, Russia, Any
other Mediterranean country)
F: White –
United Kingdom
(to include England, Wales,
Scotland, Northern Ireland)
G: White –
Northern European
(to include Austria, Belgium,
Switzerland, Scandinavia, Ireland,
France, Germany, Netherlands,
Australia, North America, Canada,
South Africa, New Zealand)
H: Don’t Know
or Adopted

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2. Bone marrow transplants.

This question is to find out if you have ever had a bone marrow transplant or if either of your
biological parents had a bone marrow transplant before you were born.
You must provide an answer in each column below.
If you do not know your parents or were adopted, please check the ‘don’t know’ box.
You Biological mother Biological father

Ever had a bone

Yes Yes Yes
marrow transplant?
For your parents, No No No
this includes before
you were born. Don’t know Don’t know Don’t know

I confirm that I consent to the Royal Navy and its contracted medical assessor
(Capita) requesting and holding this information.

I confirm that I have completed this form to the best of my knowledge

For serving personnel only:

I consent to my FOQ outcome and blood test result being shared with the Defence Medical
Services in order to update my military healthcare records. I am aware that this may have an
impact on the physical activities that I am allowed to take part in.

By typing “I Agree” in the signature box I give consent as outlined in this form as an
Electronic Signature.
Signature:
Name:

Unique Number:

Date:

What do you need to do next?

Check your answers as you will not be able to change them after you have submitted them.

Submit this form to Capita with your RNMQ and Opticians report to the email below:
recruitment.medicals@capita.co.uk
Do not send this to your AFCO

If you do need a blood test, you will be contacted by a member of our team.

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