Equal Opportunities Monitoring Form
Name of Applicant / Position applied for:Gender / Male / Female
Age
16-19 / 20-29 / 30-39 / 40-49 / 50-59 / 60-65 / Over 65
Ethnic Origin
I would describe my ethnic origin as:
Asian or Asian British - Bangladeshi / Mixed – White and Asian
Asian or Asian British – Indian / Mixed - White and Black African
Asian or Asian British – Pakistani / Mixed – White and Black Caribbean
Asian or Asian British – any other Asian background / Mixed – any other Mixed background
Black or Black British – African / White – British
Black or Black British – Caribbean / White – Irish
Black or Black British – any other Black background / White – any other White background
Chinese / Any other
The categories above are consistent with those used by the Office of National Statistics (ONS) 2001 census
Disability
Under the Equality Act 2010 I consider myself to have (please tick the box that applies)
No known disability
or
Dyslexia
Other learning difficulty
Visual impairment
Hearing impairment
Mobility problem
Please indicate if you are a wheelchair user
Mental Health difficulty
‘Unseen’ disability eg. Asthma, diabetes, epilepsy
Disability other than listed
Please describe the nature of the disability
I agree to this information being shared with the interview panel. (Please tick if you do agree)
If you require any special arrangements/adjustments making for the job interview, should you be short-listed, we will contact you to discuss these arrangements further.
Please state where you saw this vacancy advertised or how you became aware of it.
Times Educational Supplement: / Academy website:
Fylde Coast Teaching School Website: / Other website, please state:
Other publication, please state: / Other, please state:
Signed / Date
Data collected on this form will be processed for the purpose of equal opportunities in the selection process. All information remains confidential and will not be circulated to the short-listing panel and does not form part of the selection process. Please note however, that it will be necessary to share information about disability during the selection process in order to ascertain what support and assistance may be required. It will form part of the personal, confidential record of the successful applicant.