Equality Monitoring Form

EQUALITY MONITORING FORM

The completion of this form or any part of it is completely voluntary on your part.

Innisfree Housing Association is committed to ensuring equality of opportunity for everybody with whom we work, including job applicants, members of staff and Board and committee members. To help us monitor the implementation of our equal opportunities policy, we would be grateful if you would complete this form and return it to us. The information you provide is confidential and will be used for monitoring purposes only.

Name:

(Please tick boxes and specify further if necessary)

Gender

Female Male

Sexuality

Heterosexual / Bisexual

Gay Man
Other /
Lesbian
Please specify………………………

Ethnic Origin (based on Categories used in the 2001 Census Survey):

This section is not to identify citizenship. Please indicate which ethnic group you consider yourself to belong to by ticking the appropriate box and if you choose “other” in any group then please add further details in the space provided. (Service providers may expand these categories further to determine fairness and take up of services by local people.)

White Black or Black British

British African

Irish Caribbean

Any other White background Any other Black background

Please specify below Please specify below

……………………………….. ……………………………………..

Dual or multiple heritage Asian or Asian British

White and Asian Bangladeshi

White and Black African Indian

White and Black Caribbean Pakistani

Any other dual/multiple heritage Any other Asian background

background. Please specify below Please specify below

…………………………………… ……………………………

Chinese or other ethnic group

Chinese

Any other ethnic background

Please specify below

………………………….

Religion

None Jewish

Buddhist Muslim

Christian Sikh

Hindu Any other religion

Please write in below

……………………………

Disability

Innisfree Housing Association operates within a framework of the Disability Discrimination Act 1995, (DDA) which defines Disability as:

“A physical or mental impairment which has substantial and long term adverse effect on a person’s ability to carry out normal day to day activities”.

Do you consider yourself to be disabled as defined by the Disability Discrimination Act?

Yes No

Age

0- 16 40 - 49 75 - 84

17- 24 50- 59 85 +

25- 39 60- 74

Thank you for completing this form