<p> NORTH YORKSHIRE COUNTY COUNCIL: APPOINTEE QUESTIONNAIRE</p><p>Section 1 </p><p>Post Title</p><p>Ref Number</p><p>Directorate</p><p>Service Unit</p><p>Establishment (Place Of Work)</p><p>Section 2 </p><p>In order to ensure that your employee record is set up correctly and to assist the Council in fulfilling its duties for monitoring equality issues please complete this form.</p><p>Please note: your full name and date of birth are required to ensure that your details are not confused with another employee with the same initials and surname. Your date of birth is also relevant in the calculation of pay, pension, National Insurance contributions and statutory sick pay.</p><p>Surname</p><p>Forename(S)</p><p>Title by which you would wish to be known (Mr / Mrs / Miss / Ms / Dr etc)</p><p>Gender (Please insert the appropriate code - M for Male or F for Female)</p><p>Date Of Birth / /</p><p>Please forward your Birth Certificate or Passport when you return this form if it has not previously been seen as part of the Asylum and Immigration check. It will be returned to you as soon as possible by Recorded Delivery. </p><p>Marital Status (Please insert the appropriate code)</p><p>M – Married P – Partner S – Single D – Divorced W – Widowed E – Separated CP – Civil Partnership CH – Co-habiting</p><p>If you do not know your National Insurance Number, please contact your local DSS Office to obtain this information. It is most important that you provide this number so that any claim for social security benefit or revised income tax allowances can be dealt with quickly by the appropriate Government Department. National Insurance Number</p><p>Other Employment</p><p>Do you have any other type of paid current employment with the Authority?</p><p>Insert “Y” for yes or “N” for no </p><p>If yes, please supply a) Directorate:</p><p> b) Post title:</p><p>If you are an employee of North Yorkshire County County please give your employee reference number (this can be found on your payslip)</p><p>Former Name(s) (Most recent first - eg maiden names)</p><p>This information is required to ensure that your details are not confused with another employee with the same name or former names. Female employees should detail their maiden name (if applicable) and any other surnames they have been known by. Male employees should detail any change of surname.</p><p>Please indicate the reason why your name changed by the appropriate code:- M - Married P - Deed Poll D - Divorced K - Wishes to be known as</p><p>Former Surname </p><p>Date Changed Reason For Change</p><p>Former Title Maiden Name : Y/N</p><p>Former Surname</p><p>Date Changed Reason For Change</p><p>Former Title Maiden Name : Y/N</p><p>Section 3: Equalities Monitoring</p><p>North Yorkshire County Council is committed to the principle of equality in employment. The Council’s aim is to ensure equality of opportunity for all existing and prospective employees. In order to assist the Council to monitor the Equality Policy, your co-operation in providing the information requested below would be appreciated. This information, which will be used solely for monitoring purposes, will be treated as strictly confidential and is subject to the provisions of the Data Protection Act 1998. </p><p>Please note: the categories below are taken from the 2001 Census. The Council is required to use this format for its monitoring exercises.</p><p>What is your ethnic group? Please place a tick in the appropriate box to indicate your cultural background:-</p><p>White Mixed British □ White and Black Caribbean □ Irish □ White and Black African □ Other (please specify)…………………… White and Asian □ Other (please specify)………………..</p><p>Asian or Asian British Black or Black British Indian □ Caribbean □ Pakistani □ African □</p><p>Bangladeshi □ Other (Please specify)……………….. Other (please specify)…………………….</p><p>Chinese or other Ethnic Group Chinese □ Other (please specify)…………………….</p><p>Disability Do you consider yourself to have a disability? Yes No (please tick the appropriate box)</p><p>Note: the Disability Discrimination Act states that: “a person has a disability for the purposes of the Act if he/she has a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-day activities”. DDA 1995</p><p>Please identify your sexual orientation: (Please insert the appropriate code)</p><p>H –Heterosexual L – Lesbian G – Gay Man B – Bisexual Please identify your religion:</p><p>Buddhist □ Christian □ Hindu □ Jewish □ Muslim □ Rastafarian □ Sikh □ No Religion □ Other (please specify):…………………………………………………………………..</p><p>Section 4: Emergency Contact</p><p>This section allows you to detail the name and address and telephone number of a person you would wish to be contacted in case of emergency, for example if you became seriously ill at work.</p><p>The completion of this section is optional.</p><p>The contact’s full name (including title)</p><p>It would be helpful if you could select and insert the appropriate code to indicate the relationship between your named Emergency Contact and yourself.</p><p>FAMILY MEMBER - 01 NEXT OF KIN : Y/N FRIEND - 02 OTHER/UNKNOWN - 03</p><p>If family member or other, please indicate exact relationship: (ie parent, partner)</p><p>The contact’s home address and telephone number</p><p>Line 1</p><p>Line 2</p><p>Town</p><p>County Post code Home Telephone No (Please include national STD code)</p><p>Work / Mobile Telephone No (Please include national STD code)</p><p>Section 5: Other</p><p>Do you perform any Public Office Duties or Armed Force or Reservist Duties? (It is your responsibility to inform you Line Manager at the start of your employment) </p><p>Yes No</p><p>Please identify your highest qualification (whether relevant to the post applied for or not)</p><p>Month & Year:</p><p>Education Establishment:</p><p>Qualification:</p>