Download Broste Rivers Equal Opportunites Form

Equal Opportunities Monitoring Form
If you have any queries or require any assistance completing this form, please email
[email protected] or call 01923 8227
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
Asian British
Asian English
Asian Scottish
Asian Welsh
Asian Irish
Bangladeshi
Indian
Pakistani
Any other Asian background
Black
Black British
Black English
Black Scottish
Black Welsh
Black Irish
African
Caribbean
Any other Black background
White
British
English
Irish
Scottish
Welsh
Any other White background
Any other Ethnic background
Prefer not to say
Chinese
Chinese British
Chinese English
Chinese Scottish
Chinese Welsh
Chinese Irish
Any other Chinese background
Mixed
White & Black African
White & Black Caribbean
White & Chinese
White & Asian
Any other Mixed background
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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
Baha’i
Jewish
Buddhist
Muslim
Christian
Sikh
Any other religion or belief
(specify if you wish)
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
45 – 54
55 – 64
Your age
16 – 24
25 – 34
35 – 44
65 +
2
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 in The 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 [email protected]
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