Bucks Students Union Equal Opportunities Monitoring Form

Bucks Students’ Union Equal Opportunities Monitoring Form

Strictly confidential

Post applied for

Ethnic originReligion/belief

I would describe my ethnic origin asWhich group do you most identify with?

White – BritishNo religion

White – IrishBaha’I

Other White background*Buddhist

Asian or Asian British – IndianChristian

Asian or Asian British – PakistaniHindu

Asian or Asian British – BangladeshiJain

Other Asian background*Jewish

Black or Black British – CaribbeanMuslim

Black or Black British – AfricanOther (please specify)*

Other Black background*

ChinesePrefer not to say

Mixed – White or AsianSexual orientation

Mixed – White and Black CaribbeanWhich of the following best describes you?

Mixed – White and Black AfricanBisexual

Other Mixed background*Gay man
Other Ethnic background *Heterosexual/straight

Prefer not to sayLesbian/gay woman

*Please specify Prefer not to say

Marital status

NationalityAre you?

What is your nationality? Married

Separated/divorced

Single (never married)

Widowed

Prefer not to say

Other (please specify)

Bucks Students Union Equal Opportunities Monitoring Form (February 2016)

Gender

Male Female

Is your gender identity the same as the gender you were assigned at birth?

Yes

No

Prefer not to say

Do you live and work full-time in the gender role opposite to that assigned at birth?

Yes

No

Prefer not to say

Disability

Disability is defined in the Disability Discrimination Act 1995 as a physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities. The impairment is long term if it has lasted 12 months or is expected to last at least 12 months.

Do you consider yourself to have a disability?

Yes

No

Prefer not to say

If yes, please tick the type of impairment which applied to you (you may tick more than one type)

Specific learning disability, such as dyslexia or dyspraxia

General learning disability, such as Down’s

Syndrome

Cognitive impairment, such as austic spectrum disorder or resulting from head injury

Long standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy

Mental health condition, such as depression or schizophrenia

Physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or

crutches

Deaf or serious hearing impairment

Blind or serious visual impairment

Other type of disability

Age

Date or birth

Bucks Students Union Equal Opportunities Monitoring Form (February 2016)