Equal Opportunities Monitoring Form
If you have any queries or require any assistance completing this form, please email or call 01923 278133

PLEASE COMPLETE IN BLACK INK OR TYPE

PLEASE NOTE: This part of the application will be detached by Human Resources and will not be used in the selection process. Your answers will be treated confidentially and will not affect your job application in any way.

We operate an Equal Opportunities policy which is based upon the principle of appointing on merit regardless of age, gender, race, religion or belief, sexual orientation or disability. We want to find out whether this policy is working and take steps to ensure further progress is made to action equal opportunities.

In order to monitor our policy we need to know about the people who apply to join our service.

The survey is based on that devised by the Equality and Human Rights

Please return the completed questionnaire with your application form. May we thank you in advance for your co-operation.

Name: Job Title:

Your ethnic group: (please tick the box that best applies to you)

Asian / Black / White
Asian British / Black British / British
Asian English / Black English / English
Asian Scottish / Black Scottish / Irish
Asian Welsh / Black Welsh / Scottish
Asian Irish / Black Irish / Welsh
Bangladeshi / African / Any other White background
Indian / Caribbean
Pakistani / Any other Black background / Any other Ethnic background
Any other Asian background
Prefer not to say
Chinese / Mixed
Chinese British / White & Black African
Chinese English / White & Black Caribbean
Chinese Scottish / White & Chinese
Chinese Welsh / White & Asian
Chinese Irish / Any other Mixed background
Any other Chinese background

Your Gender

Male Female Prefer not to say

Do you identify as transgender?

For the purpose of this question “transgender” is defined as an individual who lives, or wants to live, full time in the gender opposite to that they were assigned at birth.

Yes No Prefer not to say

Do you have a religion or belief? Yes No Prefer not to say

If yes, please specify which:

Hindu / Jain / Any other religion or belief (specify if you wish)
Baha’i / Jewish
Buddhist / Muslim
Christian / Sikh

Your sexual orientation

Bisexual / Heterosexual/straight
Gay woman / Other (specify if you wish)
Gay man / Prefer not to say

Martial Status

Single Married Divorced Widowed Civil Partnership Prefer not to say

Your age

16 – 24 / 25 – 34 / 35 – 44 / 45 – 54 / 55 – 64

65 +

Your Disability

The Equality Act 2010 protects disabled people. The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (i.e. has lasted or is expected to last 12 months) and has an adverse effect on the person’s ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability according to the terms given inThe Equality Act 2010?

Yes No

If you have answered YES, please indicate the type of impairment which applies to you (by ticking next to it below)

People may experience more than one type of impairment, in which case tick all the types that apply. If your disability does not fit any of these types, please mark ‘Other’.

  • Physical impairment, such as difficulty using your arms or mobility issues which means using a wheelchair or crutches

  • Sensory impairment, such as being blind / having a serious visual impairment or being deaf / having a serious hearing impairment

  • Mental health condition, such a s depression or schizophrenia

  • Learning disability, (such as Down’s syndrome or dyslexia) or cognitive impairment (such as autism or head-injury

  • Long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy

  • Other, such as disfigurement (specify below if you wish)

You can seek information on any of the classifications in this form from the Human Resources Team.

Once completed please e-mail to

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