SAGE – Greenfingers Equal Opportunities Monitoring Form

SAGE is committed to engaging with as diverse a community as possible in all aspects of our outreach. This applies equally to our outreach to potential clients, volunteers and staff. For this reason we ask you to complete the following form. The data you submit will be completely anonymous and not linked to your name in anyway. It will help us know how successful we are at reaching out widely and it will prompt us to change our practice if we are not successful. Some sections are only relevant to potential staff. Please fill in all sections that are relevant to yourself. If you do not understand any sections or would like an interpreter to support you, please ask a member of staff. Thank you for your co-operation

______

GenderMale ____Female ____

______

Age16-24 ___25-29 ___30-34 ___35-39 ___40-44 ___

45-49 ___50-59 ___60-64 ___ 65+ ___

______

How would you describe your nationality?

English ___Welsh ___Scottish ___Northern Irish ___British ___Other ___

______

What is your ethnicity?

Ethnic origin categories are not about nationality, place of birth or citizenship. They are about the group to which you as an individual perceive you belong. Please indicate your ethnic origin with a tick.

White

English ___Welsh ___Scottish ___Northern Irish ___

Irish ___Gypsy or Irish Traveller ___Other white background ___

Mixed/ multiple ethnic group

White & Black Caribbean ___White & Black African ___

White & Asian ___Any other mixed background ___

Asian / Asian British

Indian ___Pakistani ___Bangladeshi ___Chinese ___

Any other Asian background ___

Black / African/ Caribbean / Black British

African ___Caribbean ___ Any other Black / African / Caribbean ___

Other Ethnic group

Arab ___Any other ethnic group – please specify ______

______

Do you consider yourself to be disabled? Yes ___No ___

What is your sexual orientation?

Heterosexual / straight ___Gay women / lesbian ___

Gay man ___Bisexual ___Other ___

What is your religion of belief?

No religion ___Buddhist ___Christian ___Hindu ___

Jewish ___Muslim ___Sikh ___Any other religion ___

______

What is your current working pattern? (potential staff only)

Full-time ___Part-time ___Prefer not to say ___

______

What is your flexible working arrangement? (potential staff only)

None ___Flexi-time ___Staggered hours ___Term-time hours ___

Annualised hours ___Job share ___Flexible shifts ___Compressed hours ___

Homeworking ___Other ___

______

Do you have caring responsibilities? (potential staff only)

If yes please tick all that apply

None ___

Primary carer of a child/ children (under 18yrs) ___

Primary carer of disabled child / children ___

Primary carer of disabled adult ___

Primary carer of older person (65+) ____

Secondary carer ___

Prefer not to say ___

______

By completing this form you have helped us better understand how we, as an organisation, ensure equality of opportunity for all

Thank you for completing this form

C:\docs\Admin - restricted access\Equal Opps\Equal Opps monitoring form.doc