Equal Opportunities Monitoring Form

Equal Opportunities Monitoring Form
1.0 INFORMATION

1.1 The information supplied on this form will be used in total confidence and in accordance with current Data Protection Legislation. It will help to ensure that the service properly monitors and conforms with its policies relating to the equality of opportunity.

1.2 Information will be used for monitoring and for no other purpose.

2.0 AIM

2.1 Our committed aim is to allow our support staff to develop their skills and realise their maximum potential as individuals without any wish on the part of the service to limit their opportunities.
Gender

MaleFemalePrefer not to say
Are you married or in a civil partnership?

YesNoPrefer not to say
Age

16-2425-2930-3435-3940-4445-4950-5455-5960-6465+ Prefer not to say
3.0 WHAT IS YOUR ETHNICITY?
3.1 Ethnic origin is not about nationality, place of birth or citizenship. It is about the
group to which you perceive you belong. Please tick the appropriate box:
White

EnglishWelshScottishNorthern IrishIrishBritishGypsy or Irish TravellerPrefer not to say
Any other white background, please write in:
Mixed/multiple ethnic groups

White and BlackWhite and BlackWhiteCaribbeanAfricanAsianPrefer not to say
Any other mixed background, please write in:
Asian/Asian British

IndianPakistaniBangladeshiChinesePrefer not to say
Any other Asian background, please write in:
Black/ African/ Caribbean/ Black British

AfricanCaribbeanPrefer not to say
Any other Black/African/Caribbean background, please write in:
Other ethnic group

ArabPrefer not to say
Any other ethnic group, please write in:
Do you consider yourself to have a disability or health condition?

YesNoPrefer not to say
What is the effect or impact of your disability or health condition on your ability to give your best at work? Please write in:
The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.
What is your sexual orientation?

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

No religion or beliefBuddhistChristianHinduJewishMuslimSikhPrefer not to sayIf other religion or belief, please write in:
What is your current working pattern?

Full-timePart-timePrefer not to say
What is your flexible working arrangement?

NoneFlexi-timeStaggered hoursTerm-time hoursAnnualised hoursJob-shareFlexible shiftsCompressed hoursHomeworkingPrefer not to sayOther
Do you have caring responsibilities? If yes, please tick all that apply

NonePrimary carer of a child/children (under 18)Primary carer of disabled child/childrenPrimary carer of disabled adult (18 and over) Primary carer of older personSecondary carer (another person carries out the main caring role)Prefer not to say
Should be Empty: