London College of Beauty Therapy - Monitoring Form
London College of Beauty Therapy Ltd is committed to being an equal opportunities employer and service provider. We want to ensure that all learners, employees, applicants, customers and other people with whom we have dealings .with are treated fairly and are not subjected to unfair or unlawful discrimination.
Any information given in this form will only be used to support the equal opportunities and diversity policy and, in accordance with the principles of the Data Protection Act 1998, to provide annual statutory returns to relevant Agencies. The information you give will be retained only for statistical purposes.
Do you consider that you have a disability, or a physical or mental impairment which has a substantial and long – term adverse effect on your ability to carry out normal day to day activities - (If yes, please answer question 3).
Yes: No: Decline to Specify:
Please tick one or more boxes to describe your disability,
a) Visual impairment:
b) Hearing impairment:
c) Disability affecting mobility:
d) Other physical disability:
e) Other medical conditions, e.g. epilepsy, asthma, diabetes:
f) Emotional / behavioural difficulties:
g) Mental ill health:
h) Temporary disability after illness e.g. post – viral accident:
i) Profound complex disabilities:
j) Aspergers syndrome:
k) Multiple disabilities:
l) Other Physical disability:
m) Moderate learning difficulty:
n) Severe learning difficulty:
o) Dyslexia:
p) Dyscalculia:
q) Other specific learning difficulty:
r) Autism Spectrum Disorder:
s) Multiple Learning Difficulties:
o) Other, please specify ………………………………
If you have ticked yes to any of the above) please list any adjustments or support you require:
......
......
Please state Nationality:
a) UK:
b) Other EC:
c) Other, please specify ………………………………
Age: (please tick the appropriate box)
a) 16-17:
b) 18-20:
c) 21-25:
d) 26-30:
e) 31-35:
f) 36-40:
g) 41-45:
h) 46-50:
i) 51+
Please describe your ethnic origin: (please tick one box only)
Ethnic origin questions are not about nationality, place of birth, or citizenship. They are about colour and ethnic group. Citizens of any country may belong to any of the groups indicated.
Decline to specify:
White:
a) English/Welsh/Scottish/Northern Irish/British:
b) Irish:
c) Gypsy or Traveller
d) Any other White background. Please specify: …………………………………..
Mixed/Multiple Ethnic background:
a) White and Black Caribbean:
b) White and Black African:
c) White and Asian:
d) Any other mixed/Multiple ethnic background. Please specify:......
Asian /Asian British:
a) Indian:
b) Pakistani:
c) Bangladeshi:
d) Chinese:
e) Any other Asian background, please specify: ……………………………………
Black/African/Caribbean/Black British background:
a) Caribbean:
b) African:
c) Any other Black/African/Caribbean/Black British background, please specify: ………………………
Chinese/ Chinese British:
a) Chinese:
b) Any other Chinese background, please specify: ……………………………………
Other:
a) Arab:
b) Any other ethnic group:
c) Not known/Not provided:
What is your nationality?......
What language do you speak at home?......
Do you speak any other languages?......
What is your country of birth?......
DEPENDENTS/ CARING RESPONSIBILITIES:
Do you have dependants, or caring responsibilities for family members or other persons?
a) Yes: No:
Are your dependents or the people you look after:(Please tick the appropriate box or boxes)
a) A child or children:
b) A disabled person or persons:
c) An elderly person or persons:
d) Other:
Please Specify......
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