Equal Opportunity Monitoring Form AQ1301

Equal Opportunities Monitoring Form
Policy

Anderson Quigley believes that there should be no discrimination because of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation. Anderson Quigley operates an equal opportunity policy and commits to following all obligations under the Equality Act. Anderson Quigley will take appropriate steps to ensure that all applicants are reviewed on the basis of ability and the requirements of the promoted role.

Monitoring

To ensure that the equal opportunities policy is effective, monitoring of applications will be carried out. This necessitates the collection of information regarding the applicant’s ethnic origin, sex, gender identity, marital status, disability, religion, belief, and sexual orientation. This monitoring form may also be shared with The General Dental Council for their own equality monitoring purposes.
All information will be treated as strictly confidential and in accordance with the General Data Protection Regulation (EU) 2016/679 and national laws such as the Data Protection Act 2018 as amended, re-enacted or consolidated from time to time. Please tick the following box to provide Anderson Quigley with your express consent to use and share this data with The General Dental Council as described above.*

Express consent given
Name

First NameLast Name
Sex, Gender Identity and Date of Birth
Gender

FemaleMaleNon-binaryPrefer not to answerOther
Is your gender the same as the gender you were assigned at birth?

YesNoPrefer not to answerOther
Date of Birth

MonthDayYear
Please leave blank if you prefer not to answer
Age

16–2425–2930–3435–3940–4445–4950–5455–5960–6465+Prefer not to answer
Marital Status

MarriedCivil PartnershipDivorcedSingleCo-habitingSeparatedWidowedPrefer not to answerOther
Ethnicity

The following categories have been devised by the UK governments Census of population and are recommended by the Equality and Human Rights Commission. It is important to understand that these questions are not about nationality, place of birth or citizenship.
White

EnglishWelshScottishNorthern IrishIrishBritishGypsy or Irish TravellerPrefer not to answerOther
Mixed/Multiple ethnic groups

White and Black CaribbeanWhite and Black AfricanWhite and AsianPrefer not to answerOther
Asian/Asian British

IndianPakistaniBangladeshiChineseArabPrefer not to answerOther
Black/African/Caribbean/Black British

AfricanCaribbeanPrefer not to answerOther
My Nationality is:
Please leave blank if you prefer not to answer.
What is your sexual orientation?

HeterosexualGay woman/lesbianGay manBisexualPrefer not to answerOther
What is your religion or belief?

No religion or beliefBuddhistChristianHinduJewishMuslimSikhPrefer not to answerOther
Do you consider yourself to have a disability or long-term health condition (such as dyslexia, diabetes, arthritis, a heart condition, or a mental health condition, for example)?

YesNoPrefer not to answer
Do you have any of the following disabilities, long-term conditions or mental health conditions? Select all that apply:

Hearing lossSpeech related condition e.g. a stammer or stutterSight lossMobility issues e.g. using a wheelchair or crutches some or all of the time or being unable to walk more than short distancesMental health conditions e.g. depression, anxiety, Bi-PolarWork related stressDyslexiaAutismOther neurodiverse conditions e.g. dyscalculia or ADHDMusculoskeletal conditions e.g. back, neck, shoulder or arm conditionsEnergy limiting condition e.g. chronic fatigue or fibromyalgiaLearning disabilityLong-term condition e.g. diabetes, multiple sclerosis, heart conditions, epilepsy, or chronic painManual dexterity conditions e.g. arthritisMigrainesOther (please specify)None: No disabilities or long-term conditionsPrefer not to answer
Do you require adjustments to support you through your application process?

YesNoPrefer not to answer
If you require adjustments to support you through your application process, please contact us directly on +44(0)20 3457 0948 or welcome@andersonquigley.com to discuss how we can help. Alternatively, please provide details in the box below.
Thank you - this Equal Opportunities form is now complete
Should be Empty:

Equal Opportunities Monitoring Form

Sex, Gender Identity and Date of Birth

Ethnicity

Thank you - this Equal Opportunities form is now complete