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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 1 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] 3