Equal Opportunitiesmonitoring Form

EQUAL OPPORTUNITIESMONITORING FORM

The Hospice is committed to developing a dynamic and diverse workforce representative of the communities it serves We ask you, therefore, to complete the Equal Opportunities Monitoring form and mark the box with ‘x’, where applicable to help us in this aim. This form is used for monitoring purposes only.

Name: / Position applied for:
Date of Birth: / Gender:

ETHNICITY

White / British
Irish
Any other White background (please specify)
Mixed / Black Caribbean and White
Black African and White
Asian and White
Any other mixed/multiple ethnic background (please specify)
Asian or Asian British / Indian
Pakistani
Bangladeshi
Any other Asian background (please specify)
Black or Black British / African
Caribbean
Any other Black background (please specify)
Other Ethnic Groups / Chinese
Any other ethnic group (please specify)
Arab or Middle Eastern descent / Arab
North African
Iraqi
Kurdish
Any other Middle Eastern background
Not stated in groups above (please specify)
Prefer not to say

Religion and Beliefs

Buddhism / Judaism
Christianity / Sikhism
Hinduism / None
Islam / Prefer not to say
Other philosophical belief or religion (please specify)

Gender

Female / Male / Prefer not to say

SEXUAL ORIENTATION

Heterosexual / Gay / Lesbian / Bisexual / Prefer not to say

Disability

The Equality Act 2010 protects disabled people – including those with long term health conditions, learning disabilities and so called “hidden” disabilities such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes including the interview are fair and equitable. Do you consider yourself to have a disability?

Yes / No / Prefer not to say

Please state the impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’:

Physical Impairment / Sensory impairment
Mental health / Learning disability/difficulty
Long standing illness / Other
Prefer not to say
Please specify any reasonable adjustments required:

DECLARATION

I understand that this document is confidential and will be used for monitoring purposes only; it will not be part of the short-listing process.

Signature: / Date:

THANK YOU FOR TAKING THE TIME TO COMPLETE THE FORM.