EQUAL OPPORTUNITIES & IMMIGRATION IN RECRUITMENT MONITORING FORM

NHS Lanarkshire committed to providing equal opportunities in its employment practices.

It is our policy to ensure that no job applicant receives less favorable treatment on the ground of sex, marital status, race (including colour, nationality, ethnic or national origin), disability, age, responsibility for dependants, sexuality, creed, political party or trade union membership, HIV/AIDS status.

To help achieve this, please complete the following questionnaire, which is treated as strictly confidential. This information will be separated from your application form on receipt and will be used by the Medical Personnel Department for monitoring purposes only.

Under no circumstances will this information be made available to managers or panel members involved in the recruitment process.

Thank you for your assistance.

(Please tick all the boxes where appropriate.)

POST APPLIED FOR:
DEPARTMENT/LOCATION:
SURNAME:
MAIDEN NAME:
FORENAMES:

TITLE

Mr / Ms
Mrs / Dr
Miss / Reverend
Other

SEX

Male / Female

DATE OF BIRTH

Date: / Month: / Year:

AGE (Years)

MARITAL STATUS

Single / Divorced
Married / Separated
Widowed

DRIVING LICENCE

Do you have a driving licence?

Yes No

NATIONALITY

COUNTRY OF BIRTH

ETHNIC ORIGIN

A: White

Scottish / Irish / Other British / Any other White background

B: Mixed

Any mixed background

C: Asian; Asian Scottish; Black British

Pakistani / Indian / Chinese / Bangladeshi
Any other Asian background

D: Black; Black Scottish; Black British

Caribbean / African / Any other Black background

E: other ethnic background

Any other background

F: Prefer not to answer

TO WHICH RELIGION, RELIGIOUS DENOMINATION OR BODY DO YOU ACTIVELY BELONG?

Christianity (Church of Scotland) / Buddhism
Christianity (Roman Catholic) / Hinduism
Christianity (Other) / Islam
Other faith / belief / Judaism
No religion (none) / Sikhism
Prefer not to answer

WHICH OF THE FOLLOWING BEST DESCRIBES YOUR SEXUAL ORIENTATION?

Bisexual / Gay Man
Heterosexual (straight) / Lesbian/Gay Woman
Other / Prefer not to answer

DEPENDENT RELATIVES

Yes No

Please give brief details including age:

DISABILITY

Do you consider yourself to have a disability?

Yes No

Do you have a physical or mental health condition or disability that has a substantial effect on your ability to carry out day to day activities and has lasted or expected to last 12 months or more

Yes No

This information is required to ensure that all applicants who have a disability and meet the minimum criteria for this position are offered an interview. Please specify any special requirements you require if attending for interview (e.g. induction loop, wheelchair access, signer) ……………………………….....

RECRUITMENT METHOD

How did you find out about this vacancy?

Newspaper (which one?)
Professional Journal (which one?)
Internal Vacancy Bulletin
SHOW (Scottish Health On The Web)
Job Centre Plus
Other (Please specify)

IMMIGRATION STATUS

We need to know if you are eligible for employment in theUK .

PLEASE READ ALL QUESTIONS CAREFULLY BEFORE COMPLETING THIS FORM
Please use BLOCK CAPITALS and tick the appropriate responses.
1 / Are you a citizen of the European Economic Area?
If you have answered YES, please attach proof (i.e copy of passport) and go straight to section 6
(If you are a citizen of Eastern Europe, you must provide a copy of the Workers Registration)
If you have answered NO, please answer questions 2-6 / YES / NO
2 / Passport Expiry date / Day: / Month: / Year:
(a) Passport Number……………………………….
3 / Date of Entry to theUK / Day: / Month: / Year:
4 /

Status of Entry – please NUMBER as appropriate, ie 1, 2, 3 and ensure 4(a) is completed in relation to the numbers stated

Visitors Permit
Settled status/ indefinite residence
Spouse of someone with settled status/ indefinite residence / Work Permit
Refugee/ Asylum
Spouse of overseas national with work permit or permit free training / Exceptional leave to remain
Commonwealth Citizen with grandparents born in theUK / Highly Skilled Migrant Workers Programme
Permit Free Training / Spouse of a British Citizen
Other (please specify and enclose appropriate documentation)
………………………………………………………………………………………………………………………………………….
4 (a) PLEASE PROVIDE FULL INFORMATION/DATES FOR ALL FORMS OF IMMIGRATION STATUS YOU HAVE
NUMBERED ABOVE
1. From …………………………To……………………….. 2. From………………………………….To………………
3. From…...... To……………………….. 4. From…………………………………To..……………..
5 / Date the current UK leave expires (visa expiry) / Day: / Month: / Year:
If you have answeredquestions 2 to 5, please attach the following documentation (photocopies are acceptable):
/

Passport

  • Visa
  • Letter of Immigration status from the Home Office (if applicable)

Documents in foreign languages must be accompanied by certified translations into English

6 / I confirm that the information provided on this form is to the best of my knowledge correct. I understand that failure to enclose the required documentation will mean my application cannot be considered for employment.
SIGNATURE ………………………………………………………………………………………………………………...
PRINT NAME………………………………………………………………………… DATE………………………………

1

December 2006

PB/MF/Proformas.doc