Equality Monitoring Form (10/16)

Name: ______Date of Birth: ______

Please complete this form to help us develop and monitor how our workplace policies and practices affect staff with different protected characteristics. We encourage full disclosure but we do recognise that some people may prefer not to disclose all or some of this personal data, in which case please select ‘prefer not to say’. For more information on how we use your ED&I data click here

Gender ¨ Male ¨ Female ¨ Other ¨ Prefer not to say Ethnicity ¨ White – British ¨ White – Irish Is your gender identity the same as the gender you were assigned at birth? Gender ¨ Gypsy or Irish Traveller Identity ¨ Yes ¨ No ¨ Prefer not to say ¨ Other White background ¨ Black or Black British – Caribbean Disability ¨ No known disability ¨ Black or Black British – African ¨ Two or more impairments and/or disabling medical conditions ¨ Other Black background ¨ Specific learning difficulty, such as dyslexia, dyspraxia or AD(H)D ¨ Asian or Asian British - Indian ¨ General learning disability (such as Down's syndrome) ¨ Asian or Asian British - Pakistani ¨ A social/communication impairment, such as Asperger’s syndrome/other autistic ¨ Asian or Asian British - Bangladeshi spectrum disorder ¨ Chinese ¨ Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic ¨ Other Asian background heart disease, or epilepsy ¨ Mixed – White and Black Caribbean ¨ A mental health condition, such as depression, schizophrenia or anxiety disorder ¨ Mixed – White and Black African ¨ A physical impairment or mobility issues, such as difficulty using arms or using a ¨ Mixed – White and Asian wheelchair or crutches ¨ Other Mixed background ¨ Deaf or serious hearing impairment ¨ Arab ¨ Blind or a serious visual impairment uncorrected by glasses ¨ Other Ethnic Group ¨ A disability, impairment or medical condition that is not listed above ¨ Not Known ¨ Prefer not to say ¨ Prefer not to say

Sexual ¨ Heterosexual/Straight ¨ Gay woman/Lesbian Nationality orientation ¨ Bisexual ¨ Other ¨ Gay ¨ Prefer not to say Marital Status ¨ Single ¨ Co-habiting Religion or ¨ No religion ¨ Muslim ¨ Married or in civil partnership belief ¨ Christian ¨ Sikh ¨ Separated (but still legally married or in a civil partnership) ¨ Buddhist ¨ Spiritual ¨ Divorced or civil partnership dissolved ¨ Hindu ¨ Any other religion ¨ Widowed or a surviving partner from a civil partnership ¨ Jewish ¨ Prefer not to say ¨ Prefer not to say

Thank you for taking the time to complete this form