Equal opportunities monitoring form
Caritas Anchor House is an Equal Opportunities employer. We will provide equal opportunities to all employees and job applicants and will not discriminate either directly or indirectly on the grounds of gender, race, colour, ethnic origin, nationality, marital status, parental status, disability, sexual orientation, age, religious-, political or philosophical beliefs, class, responsibility for dependents, ex-offender status or any other grounds which cannot be shown to be justifiable within the context of our Equal Opportunities Policy.
This questionnaire is not obligatory but by completing it you will help us monitor the effectiveness of our equal opportunities policy and allow for the collation and reporting of sensitive data for monitoring purposes. All of the questions on this form are optional.
Please be assured that this form will be detached from your application on receipt and will not form part of the selection process. Any information provided will be treated with the strictest confidence, kept securely for 6 months in line with our Recruitment Policy and will be used solely by our Human Resources department for the purpose of providing statistics for equal opportunities monitoring.
Thank you for your assistance in completing this form.
Position applied for: (Job Title)
…………………………………………………………………………………………………………………….
1. Please state how you found out about the job, clearly stating the press, network, website, mailing list, etc.
…………………………………………………………………………………………………………………………………………………………………………
2. Are you
( ) Female ( ) Male ( ) Transsexual
( ) Undergoing or have already undergone male to female gender reassignment
( ) Undergoing or have already undergone female to male gender reassignment
( ) Prefer not to say
3. Which age range do you fall into?
( ) ( ) ( ) ( ) ( )
0–19 20-34 35-49 50-64 65+
( ) Prefer not to say
4. How would you describe your ethnic origin?
Asian or Asian British
( ) Asian Bangladeshi
( ) Chinese
( ) Asian Indian
( ) Asian Pakistani
( ) Any other Asian background, please state
…………………………………………
Black or Black British
( ) African
( ) Caribbean
( ) Any other Black origin, please state
……………………………………………
Mixed Heritage
( ) White and Asian
( ) White and Black African
( ) White and Black Caribbean
( ) Other Mixed / Multiple ethnic background please state
…………………………………………….
Other ethnic background
( ) Arab
( ) Other ethnic background, please state
……………………………………………..
White
( ) British
( ) Gypsy or Irish Traveller
( ) Irish
( ) Any other White background, please state
…………………………………………….
( ) Prefer not to say
5. Do you consider yourself to have a disability?
Disability is defined by the Equality Act 2010 as:
A physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities. The disability could be physical, sensory or mental and must be expected to last at least 12 months.
Are you a disabled person as defined by the Equality Act 2010?
( ) Yes – if yes, please specify:
( ) Visual impairment
( ) Hearing impairment
( ) Physical disabilities
( ) Cognitive or learning disabilities
( ) Mental health condition
( ) Invisible disabilities
( ) Other long term/ chronic conditions
( ) No
( ) Prefer not to say
6. Do you have dependents? Dependents might include children, the elderly, or other people who rely on you for care.
( ) Yes
( ) No
( ) Prefer not to say
7. How would you describe your religion or belief?
( ) Agnostic
( ) Atheist
( ) Baha’i
( ) Buddhist
( ) Christian
( ) Hindu
( ) Humanist
( ) Jain
( ) Jewish
( ) Muslim
( ) Rastafarian
( ) Sikh
( ) Zoroastrian
( ) None
( ) Not known
( ) Other religion (please give details)
( ) Prefer not to say
For the purposes of compliance with the Data Protection Act 1998, I hereby confirm that by completing this form I give my consent to Caritas Anchor House processing the data I supplied for the purpose of equal opportunities monitoring.
Signed ……………………………………………………………………………..
Date ……………………………………………………………………………..
Equal opportunities monitoring form
We are a registered charity in England (no. 1147794) and a registered company (no. 08075329) in England and Wales
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