Anglia & Oxford Regional Health Authority

OXFORD DEANERY

The Oxford Deanery is committed to Equal Opportunities for all. In order that we may monitor this policy I should be grateful if you would complete the following questionnaire and return this sheet with your Curriculum Vitae and Application Form (if applicable).

This information is used solely for monitoring purposes and will be treated as confidential. This questionnaire will be detached from your curriculum vitae and/or application form and will be retained in the Medical Personnel Office. This information will not be available for use in shortlisting and selecting staff.

The personal data on this form is stored on computer and is subject to the provisions of the Data Protection Act 1998.

1 Name : Surname : ______

Forename(s) : ______

2 Post applied for: ______

3 Job Reference Number: ______

4 Marital Status : Married Single

5 Sex : Male Female

6 Date of Birth: ______Age ______

7 Have you any dependent children? Yes No

8 Do you wish to apply for the Flexible Training Scheme (i.e. less than full-time training)? Yes No If yes, please inform the Medical Personnel Department at the time of application.

9 How would you describe your ethnic origin:

0 White 1 Black Caribbean 2 Black African 3 Black Other 4 Indian 5 Pakistani 6 Bangladeshi 7 Chinese 8 Any other ethnic group Please Name ______

10 Country of birth: ______

11 Nationality: ______

12 Do you consider yourself to have a Yes No disability you would like to tell us about?

Nature of Disability: ______

______

Medpers/Forms/EqualOpForm/16.11.00