Intellectual Property Office (IPO), Non- Executive Director

Diversity form

November 2017

DIVERSITY MONITORING FORM
Public appointments are made on merit in accordance with the Cabinet Office Governance Code and the Public Appointments Order in Council. By completing the attached diversity monitoring form you will be helping us meet our public sector equality duty under section 149 of the Equality Act 2012.
Your personal data will always be treated in confidence and when anonymised with data from other applicants will help compile the Annual Statistical Bulletin of the Commissioner for Public Appointments.
Your responses to the questions on this form will never be made available to the panel considering your application.
1.  Gender
What is your gender?
☐ Female
☐ Male
☐ I prefer to describe myself as:
☐ I prefer not to say
2.  Disability
Do you consider yourself to be disabled?
☐ No
☐ Yes
☐ I prefer not to say
Under the Guaranteed Interview Scheme, if you are a disabled applicant (as defined under the Equality Act 2010) and you meet the minimum criteria for the role, you will be selected for interview.
Please put a mark [x] below, if you would like to be considered under the Guaranteed Interview Scheme.
☐ I would like to be considered under the Guaranteed Interview Scheme
3.  Ethnicity
Please mark the box that most accurately describes your ethnicity:
Asian Black
☐ Bangladeshi ☐ African
☐ Chinese ☐ Caribbean
☐ Indian ☐ Other Black origin
☐ Pakistani
☐ Other Asian origin
Mixed Ethnic White
☐ I am of more than one ☐ British, Irish or other White Background
ethnicity
☐ I prefer not to say
4.  Age
Please tick the box that corresponds to your age band:
☐ 18-25 ☐ 26-35 ☐ 36-45 ☐ 46-55 ☐ 56-65 ☐ 66 or older
☐ I prefer not to say
5.  Sexual Orientation
What is your sexual orientation?
☐ Bisexual ☐ Gay man ☐ Heterosexual ☐ Lesbian ☐ Other ☐ I prefer not to say
6.  Religion or belief
What is your religion or belief?
☐ Buddhist ☐ Christian ☐ Hindu ☐ Jewish ☐ Muslim ☐ Sikh
☐ Other ☐ No Religion or Atheist ☐ I prefer not to say
7.  Where is your principle place of residence?
Please enter the County or City that you live in, along with the first part of your postcode. (For example, Dyfed SY23; London SE18)
County/City: Postcode:
☐ I prefer not to say
8.  What is your principle employment, if any?
Please describe your main employment and tick the occupational sector box that best describes you.
Employment:
☐ Mostly Civil Service
☐ Mostly Third Sector
☐ Mixed
☐ Mostly Private Sector
☐ Mostly wider Public Sector
☐ Other:
☐ I prefer not to say
9.  Do you hold any other public appointments?
☐ 0
☐ 1
☐ 2
☐ 3
☐ 4
☐ 5-9
☐ 10 or more
☐ Prefer not to say

© Crown copyright 2017

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Contacts us if you have any enquiries about this publication, including requests for alternative formats, at:

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Department for Business Energy and Industrial Strategy
1 Victoria Street
London SW1H 0ET
Tel: 020 7215 5000

Email:

BEIS/17/MAY

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