NES APPRAISAL
3-step guide to completing this Equal Opportunity Monitoring form:
1)Save this form (using “Save As”) to your computer (e.g. My Documents, Desk top), and rename the file to your name with an EO prefix (e.g. “EO John Smith”)
2)Proceed by filling out the form (all the grey boxes). When finished, Save and Close the document;
3)Emailand attach the Equal Opportunities formand completed applicationfrom where you had saved it, (from step 1).
EQUAL OPPORTUNITY MONITORING FORM - STRICTLY CONFIDENTIAL
NES is committed to promoting equality and diversity in everything we do. In order to support this, we monitor the equality and diversity profile of our workforce. The data you provide on the monitoring form will be kept absolutely confidential and will be securely processed and held in accordance with the Data Protection Act. We will review and analyse the results of our equality and diversity monitoring to improve our services and to make sure they are meeting the needs of Scotland’s diverse population.We hope that you will complete this form and support our efforts. If you have any questions about this form, please .
Please complete in BLOCK CAPITALS
NAME: / GMC Number:ROLE APPLIED FOR: / Medical Appraiser / DATE OF BIRTH:
(dd/mm/yyyy)
PRESENT NATIONALITY: / COUNTRY OF BIRTH:
Prefer not to answer
NES APPRAISAL
Please tick the appropriate box
1)ETHNIC GROUP
Choose one section from a) to e), then tick the appropriate box to indicate your ethnic background.
Prefer not to answer
a)White
Scottish
English
Welsh
Irish
Any other white background *
* Please describe:
b)Mixed
Please describe:
c)Asian, Asian Scottish, Asian English, Asian Welsh, or other Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background *
* Please describe:
d)Black, Black Scottish, or Black Caribbean
Caribbean
African
Any other black background *
* Please describe:
e)Other ethnic background
Please describe:
The grey text boxes expand as you type
2)CURRENT MAIN POST
Please describe:
3)SEX
Male Female
Have you undergone, are you undergoing or do you intend to undergo gender reassignment. For example, this includes having changed your sex (gender)?
Yes No
Prefer not to answer
4)SEXUAL ORIENTATION
Bisexual
Gay Man
Gay Woman / Lesbian
Heterosexual / Straight
Prefer not to answer
5)RELIGION or BELIEF
Buddhism
Hinduism
Islam
Judaism
Sikhism
Christianity – Church of Scotland
Christianity – RomanCatholic
Other Christian *
* Please describe:
Other Religion **
** Please describe:
No Religion
Prefer not to answer
6)DISABILITY
Do you consider yourself disabled according to the Disability Discrimination Act 1995 (as amended in 2005), where 'disability' is defined 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?"
Yes No
If Yes, please state briefly the nature of your disability. If you experience more than one type of impairment, you may indicate more than one:
Learning Disability / Difficulty
Long-Standing Illness
Mental Health Condition
Physical Impairment
Sensory Impairment
Other *
Prefer not to answer
* Please describe:
7)WHERE DID YOU FIRST HEAR ABOUT THIS COURSE?
Internet
Word of Mouth
BMJ
Flyer
Other *
* Please describe: