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