<p>Equal Opportunity Monitoring Form</p><p>Confidential</p><p>Reference No. ______</p><p>Date of Birth: ______</p><p>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.</p><p>We do not discriminate but aim to select the best person for the job through objective recruitment decisions.</p><p>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.</p><p>We are required, under the Fair Employment and Treatment (NI) Order 1998, to monitor community background and gender of all applicants. </p><p>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.</p><p>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.</p><p>Community Background</p><p>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 </p><p>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.</p><p>GENDER</p><p>Male  Female </p><p>1 Marital/Civil Partnership Status</p><p>Are you Married or in a Civil Partnership? </p><p>Yes  No </p><p>Dependents/Caring Responsibilities</p><p>No caring responsibilities  Care for children  Care for disabled person/s  Other  Please specify ______Care for elderly person/s </p><p>Disability</p><p>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.</p><p>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</p><p>Physical impairment – such as difficulty using your arms or mobility issues requiring you to use a wheelchair or crutches </p><p>Sensory impairment - such as being blind or having a serious visual impairment, or being deaf or having a serious hearing impairment. </p><p>Mental health condition – such as schizophrenia or depression. </p><p>Learning disability/difficulty – such as Down’s Syndrome or dyslexia, or Cognitive Impairment such as autistic spectrum disorder. </p><p>Long standing progressive illness or health condition – such as cancer, HIV infection, diabetes, epilepsy or chronic heart disease. </p><p>Other (please specify)  ______</p><p>2 Racial Group</p><p>Please state your country of birth ______</p><p>Please state your nationality ______</p><p>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 ______</p><p>Age 16.17  25-49  18-24  50+ </p><p>Sexual Orientation Heterosexual  Homosexual  Transgender  Bisexual  Transsexual  Unstated </p><p>Political Opinion Unionist generally  Member/supporter of other political party  Nationalist generally  Member/supporter of no political party  Unstated </p><p>Thank you for your co-operation</p><p>3</p>