Equal Opportunity Monitoring Form

Confidential

Reference No. ______

Date of Birth: ______

We are an Equal Opportunities employer, aiming to provide equality of opportunity to all persons regardless of their religious belief; political opinion; gender; race; age; sexual orientation; whether they are married or in a civil partnership; whether they are disabled; whether they have undergone, are undergoing or intend to undergo gender reassignment.

We do not discriminate but aim to select the best person for the job through objective recruitment decisions.

You are encouraged to answer all questions on this form as the information provided assists us measure the effectiveness of our equal opportunity policy and to promote equality of opportunity.

We are required, under the Fair Employment and Treatment (NI) Order 1998, to monitor community background and gender of all applicants.

Your identity is kept anonymous, information is handled only by our Monitoring Officer and is not available to any person in a recruitment exercise or during employment. Your answers will be treated with the strictest confidence.

If you answer the following two questions you are obliged to do so truthfully as it is a criminal offence under the Fair Employment (Monitoring) Regulations (NI) 1999 to knowingly give false answers.

Community Background

I am a member of the Protestant Community  I am a member of the Catholic Community  I am a member of neither the Protestant nor Catholic Community 

If you do not answer the above question or if you tick member of neither community we are encouraged to use the Residuary method of making a determination on the basis of the personal information supplied by you in your application form/personnel records.

GENDER

Male  Female 

1 Marital/Civil Partnership Status

Are you Married or in a Civil Partnership?

Yes  No 

Dependents/Caring Responsibilities

No caring responsibilities  Care for children  Care for disabled person/s  Other  Please specify ______Care for elderly person/s 

Disability

Under the Disability Discrimination Act 1995 you are deemed to be a disabled person if you have a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out day to day activities. You are also deemed to be a disabled person if you have cancer, multiple sclerosis or HIV infection.

Do you consider that you are a disabled person? Yes  No  If yes, please indicate the nature of your impairment by ticking the appropriate box

Physical impairment – such as difficulty using your arms or mobility issues requiring you to use a wheelchair or crutches 

Sensory impairment - such as being blind or having a serious visual impairment, or being deaf or having a serious hearing impairment. 

Mental health condition – such as schizophrenia or depression. 

Learning disability/difficulty – such as Down’s Syndrome or dyslexia, or Cognitive Impairment such as autistic spectrum disorder. 

Long standing progressive illness or health condition – such as cancer, HIV infection, diabetes, epilepsy or chronic heart disease. 

Other (please specify)  ______

2 Racial Group

Please state your country of birth ______

Please state your nationality ______

Please state which of the following applies to you: Chinese  Irish Traveller  Indian  Black African  Pakistani  African Caribbean  White  Black Other  Mixed Ethnic Specify  ______Other Specify ______

Age 16.17  25-49  18-24  50+ 

Sexual Orientation Heterosexual  Homosexual  Transgender  Bisexual  Transsexual  Unstated 

Political Opinion Unionist generally  Member/supporter of other political party  Nationalist generally  Member/supporter of no political party  Unstated 

Thank you for your co-operation