Confidential

(please put in a separate envelope)

Equal Opportunities in employment – Monitoring form

This information WILL NOT be used or seen by those involved in the selection process. It will be separated on receipt and treated as confidential.

The Care Forum aims to offer equal opportunity in employment. To assist us with the monitoring for this policy and for that purpose only, please provide the details below.

Please tick where appropriate:

  1. What is your ethnic group

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White British

White Irish

Gypsy / Traveller

Any Other White Background

Dual Heritage White and Black Caribbean

Dual Heritage White and Black African

Dual Heritage White and Asian

Any other Dual Heritage background

Asian or Asian British Chinese

Asian or Asian British Indian

Asian or Asian British Pakistani

Asian or Asian British Bangladeshi

Any other Asian or Asian British background

Black or Black British Caribbean

Black or Black British African Somali

Black or Black British African Other

Any other Black or Black British background

Any other ethnic background

Prefer not to say

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  1. Disability is defined by the Disability Discrimination Act (1995) 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’.

Do you consider yourself to have a disability as defined by the Disability Discrimination Act (1995)?

Yes□ No□Prefer not to say

If yes what is the nature of your disability?

______

  1. What is your religion?

Christian□ Hindu

Muslim□ Jewish

Sikh□ Any other religion

No religion□ Prefer not to say

  1. What is your Sexual Orientation?

Lesbian/ gay

Bisexual

Heterosexual

Prefer not to say

  1. What is your Gender?

Female

Male

 Prefer not to say

  1. Are you Transgender?

Yes

No

 Prefer not to say

  1. What is your Age?

18 or under

19-25

25-34

35-44

45-54

55-64

65-74

75-84

85 and over

  1. Your marriage or civil partnership status

□Never married and never registered in a same sex civil partnership

□Married

□Separated but still legally married

□Divorced

□Widowed

□In a registered same-sex civil partnership

□Formerly in a same-sex civil partnership which is now legally dissolved

□Surviving partner from a same-sex civil partnership

  1. Do you have any caring responsibilities. e.g. children, people with physical or learning impairments, elderly relatives? (please tick)

□ Yes□No

  1. How did you hear about this post?

Please specify the name of the website, newspaper etc.

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