The Queen S University of Belfast

Application Insert 3 Queen’s University of Belfast Doctorate in Clinical Psychology EQUAL OPPORTUNITIES MONITORING FORM – 2017 Insert 2 monitors applications for the Northern Ireland Health and Social Services. This insert monitors applications on behalf of the D.Clin.Psych. course at Queens. The information will be treated as strictly confidential. The form will be separated from your application and used for statistical purposes only after selection has taken place. For each item, please give the code for the category into which you fall.

1. GENDER Female = 1 Male = 2

2. AGE <25 = 1 25-34 = 2 35-44 = 3 >45 = 4

3. MARITAL STATUS Single = 1 Married, civil partnership or cohabiting = 2 Widowed = 3 Divorced/ separated = 4

4. RELIGIOUS AFFILIATION

I am a member of the Protestant community =1 I am a member of the Roman Catholic community =2 I am a member of neither the Protestant nor the Roman Catholic community. =3

5. DO YOU HAVE DEPENDENTS? Yes = 1 No = 2

6. PLEASE INDICATE YOUR ETHNIC ORIGIN (origin of recent forebears)

White = 1 Pakistani = 6 Black - Caribbean = 2 Bangladeshi = 7 Black- African = 3 Chinese = 8 Black - Other = 4 Irish Traveller = 9 Indian = 5 Other = 10

If other, please specify ...... ………

7. COUNTRY OF ORIGIN Northern Ireland = 1 Republic of Ireland = 2 Other UK (England, Scotland or Wales) = 3 Other EU = 4 Other Non-EU = 5

8. COUNTRY OF RESIDENCE Northern Ireland = 1 Republic of Ireland = 2 Other UK (England, Scotland or Wales) = 3 Other EU = 4 Other Non-EU = 5

9. My sexual orientation is towards: The Opposite Sex = 1 The Same Sex = 2 Both Same and Opposite Sex = 3 Would rather not say = 4

10. In line the Disability Discrimination Act 1995, a disability is defined as: “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”

Do you consider yourself to have a disability? 1 = Yes 2 =No If YES, please circle one or more below as appropriate 1 You have a specific learning difficulty (e.g. dyslexia) 2 You are blind or partially sighted 3 You have hearing difficulties 4 You use a wheelchair or have mobility difficulties 5 You have mental health difficulties 6 You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder 7 You have a disability which cannot be seen (e.g. epilepsy, diabetes, heart condition) Application Insert 3 8 Other (please specify)………