Job reference (Personnel use only)
Equal Opportunities Monitoring Form Name of Applicant
Position applied for:
Gender
Male
Female
Age 16-19
20-29
30-39
40-49
50-59
60-65
Over 65
Ethnic Origin I would describe my ethnic origin as: Asian or Asian British - Bangladeshi Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – any other Asian background Black or Black British – African Black or Black British – Caribbean Black or Black British – any other Black background Chinese
Mixed – White and Asian Mixed - White and Black African Mixed – White and Black Caribbean Mixed – any other Mixed background White – British White – Irish White – any other White background Any other
The categories above are consistent with those used by the Office of National Statistics (ONS) 2001 census
Disability Under the Disability Discrimination Act 1995 I consider myself to have - please tick the box that applies. No known disability or Dyslexia Other learning difficulty Visual impairment Hearing impairment Mobility problem Please indicate if you are a wheelchair user Mental Health difficulty ‘Unseen’ disability eg. Asthma, diabetes, epilepsy Disability other than listed Please describe the nature of the disability I agree to this information being shared with the interview panel. If you require any special arrangements/adjustments making for the job interview, should you be short-listed, we will contact you to discuss these arrangements further. Please state where you saw this vacancy advertised or how you became aware of it. Times Educational Supplement College website Blackpool Gazette Other website Other publication, please state: Other, please state:
Signed
Dated
Data collected on this form will be processed for the purpose of equal opportunities in the selection process. All information remains confidential and will not be circulated to the short-listing panel and does not form part of the selection process. Please note however, that it will be necessary to share information about disability during the selection process in order to ascertain what support and assistance may be required. It will form part of the personal, confidential record of the successful applicant.