Equal Opportunity Monitoring Form

Newcareroots Ltd has Equal Opportunities Policy. We use this “Equal Opportunity Monitoring Form” to ensure that the policy is effective. All the information given in this form will be confidential and will only be used for the purpose of monitoring and planning of our policies and procedures.

Please tick the boxes that apply to you *

Gender

Male

Female

Prefer not to say

Are you married or in a civil partnership?

16-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65+

Prefer not to say

What is your ethnicity?

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box (White)

English

Welsh

Scottish

Northern Irish

Irish

British

Gypsy / Irish Traveller

Prefer not to say

White

Please tick the appropriate box (Mixed)

English

Welsh

Scottish

Northern Irish

Irish

British

Gypsy or Irish Traveller

Prefer not to say

Mixed/multiple ethnic groups

Please tick the appropriate box (Mixed)

White & Black Caribbean

White & Black African

White & Asian

Prefer not to say

Any other mixed background, please write in

Asian / Asian British

Please tick the appropriate box

Indian

Pakistani

Bangladeshi

Chinese

Prefer not to say

Any other Asian background, please write in

Black/ African/ Caribbean/ Black British

Please tick the appropriate box

African

Caribbean

Prefer not to say

Any other Black/African/Caribbean background, please write in

Other ethnic group

Please tick the appropriate box

Arab

Prefer not to say

Any other ethnic group, please write in

Do you consider yourself to have a disability or health condition? *

Subtitle

Yes

Prefer not to say

What is the effect or impact of your disability or health condition on your ability to give your best at work? Please write in here

The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.

What is your sexual orientation? *

Please tick the appropriate box

Hetrosexual

Gay woman/lesbian

Gay man

Bisexual

Prefer not to say

If other, please write in

What is your religion or belief? *

Please tick the appropriate box

No religion or belief

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Prefer not to say

If other, please write in

What is your current working pattern?

Please tick the appropriate box

Full-time

Part-time

Prefer not to say

What is your flexible working arrangement? *

Please tick the appropriate box

None

Flexi-time

Staggered hours

Term-time hours

Annualised hours

Job-share

Flexible shifts

compressed hours

Home working

Prefer not to say

If other, please write in

Do you have caring responsibilities?

If yes, please tick all that apply

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Full Name *

Signature *

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Date *