Output Name:
Diversity Declaration form – Northern Ireland
Who is this intended for?
This is a model form that both recruitment agencies and employers can use. It is intended for
candidates to complete when they come to register with the agency or when they come to
employers to express their interest in a direct recruitment campaign.
What is its purpose?
The purpose of this form is to collect data to help measure how effective it is in attracting a
diverse range of candidates. The form also acts as a medium to communicate the employer’s
/ agency’s commitment to diversity and inclusion. The data in the form is confidential and
ideally anonymous.
The personal details being given needs to be kept separately from the information used in
recruitment decisions. It cannot in any way be used to influence recruitment decisions. The
information is to be used for statistical purposes and to ensure that policies are being applied
fairly.
Please note that the categories used in this form have been carefully considered. For example
we have included ‘Prefer not to say’ as an option for each category as, some people may avoid
completing the entire declaration form merely to avoid declaring one or two categories.
Ethnicity:
We used the ethnicity categories that will be used in the 2011 Census (based on the Test
Census forms) so that this declaration format will be relevant in the future. Census categories
were used to ensure that there would be relevant regional and national benchmarks.
Religion / Belief:
The Religion or Belief categories are also from the Test Census forms and used for the same
reasons of ensuring that users would have regional and national benchmarks based. If you
would like a more robust list of world religions, we suggest using the list below to expand the
list you have.
Buddhism
Baha'i faith
Hinduism
Rastafarianism
Sikhism
Zoroastrians
Islam
No religion (including Humanist, Atheist or
Agnostic)
Other - write in optional
Prefer not to say
Jainism
Judaism
Paganism
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Disability:
In the declaration form we have limited the disability related reporting categories to ‘Yes’, ‘No’
and ‘Prefer not to Say’. At a pre-employment stage, the logic of asking for this information is to
ensure that employers are seen as attractive to talent with disabilities, and to ensure that those
with disabilities are not being disproportionately and adversely affected at any stage of the
recruitment process. Further details on what specific disabilities candidates may have and the
reasonable adjustments needed for them have to be captured in a different way. Many
organisations mention it in their initial communication with candidates, and request that
candidates let them know if they have any reasonable adjustment needs.
Please also note that The Equality Act limits the circumstances when you can ask healthrelated questions before you have offered the individual a job. (See ACAS Guide ‘The Equality
Act – What’s New for Employers’ for further details.) At a pre-employment stage, you can only
ask health-related questions to help you to:
Decide whether you need to make any reasonable adjustments for the person to the
selection process.
Decide whether an applicant can carry out a function that is essential (‘intrinsic’) to the job.
Monitor diversity among people making applications for jobs.
Take positive action to assist disabled people.
Assure yourself that a candidate has the disability where the job genuinely requires the
jobholder to have a disability.
Sexual Orientation:
The categories used for Sexual Orientation are those recommended by Stonewall, which is the
leading organisation working for equality and justice for lesbians, gay men and bisexuals in the
UK (www. Stonewall.org.uk).
Nationality:
Some, particularly large and often multinational Employers who play a big role in driving the
diversity agenda are interested in this information in order to ensure that their organisation is
attractive to global talent. This data cannot and should not be used to understand if someone
is eligible to work or not; the report is not about compliance, but rather about diversity which is
seen as a positive, business driver. Additionally this report captures confidential data that is
kept separate from recruitment decisions.
If there is a low representation of talent from a particular country / region either at an
application or shortlisting stage, employers and / or agencies may need to consider ways in
which they can reach out to such groups.
We have left the categories largely undefined in the report as a comprehensive list of
nationalities is a very long one. We suggest that each recruitment agency and client agree on
an appropriate categorisation.
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Diversity - We measure it because it matters
We are committed to being an Equal Opportunities Employer. We wish to ensure that all
applicants are treated fairly and appointed solely on their suitability for the post irrespective of
race, gender, age, disability, caring responsibilities, sexual orientation, marital / civil
partnership status, religion / belief or nationality.
To help us measure how effective we have been in communicating with and attracting a
diverse range of people to work with, you are requested to complete and return this form.
Copies of our diversity policy are available upon request.
We are sensitive to the fact that some people would rather not complete diversity forms - either
because they fear the information will be misused, or because they consider some of the
questions to be highly personal. We would like to put your mind at rest.
We can assure you that the information being given is kept separately from the information
used in recruitment decisions. The information will not be used to influence recruitment
decisions. All information is strictly confidential, PURELY for statistical purposes and to ensure
that policies are being applied fairly; it will only be shared with a restricted number of
authorised personnel.
We will not discriminate against individuals who decide not to complete the form. However, we
ask that as many people as possible agree to help us measure diversity – because it matters
to us.
--------------------------------------------------------Name / Reference Number:
_______________________________________________
Please tick the boxes that apply to you:
Sex
Male
[ ]
Female [ ]
Prefer not to Say [ ]
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Disability Status
Do you consider yourself to have a disability?
Yes [ ]
No [ ] Prefer not to Say [ ]
What do we mean by a ‘disability’? The Equality Act of 2010 defines disability as: ‘a physical
or mental impairment with long term, substantial adverse effects on ability to perform day to
day activities.’
Examples of disabilities:
We thought it might help you to answer the question if we provided a list of some conditions or
impairments that could cause someone to describe themselves as "having a disability". It is not
meant to be an exclusive list and is given for guidance only and is recommended by the
Employers forum on Disability.
Hearing, speech or visual impairments (If you wear glasses or contact lenses this is not
normally considered a disability.)
Co-ordination, dexterity, or mobility (Examples: polio, spinal cord injury, back problems,
repetitive strain injury).
Mental health (Examples: schizophrenia, depression, severe phobias)
Speech impairment (Example: stammering)
Learning disabilities (Examples: Down’s syndrome)
Other physical or medical conditions
(Examples: diabetes, epilepsy, arthritis, cardiovascular conditions, haemophilia, asthma,
cancer, facial disfigurement, sickle cell, dyslexia etc).
We seek to provide an inclusive environment for all our applicants. However, please note that
as the information on this form is confidential, we will be unable to use it to arrange any
reasonable adjustments that you may need. For reasonable adjustments, please complete the
XXX form we have provided you, if you have not already done so.
Age
Age
[ ]
2
Religion
(Please note that
these are categories
that will be used in
the official Northern
Ireland 2011 Census
form)
I would describe my religion or belief as:
No Religion (including Humanist, Atheist or Agnostic)
Roman Catholic
Presbyterian Church in Ireland
Church of Ireland
Methodist Church in Ireland
Any other religion or belief, please write in
………………...........................................
[
[
[
[
[
[
Prefer not to say
[ ]
Sexual Orientation
What is your Sexual Orientation:
(Please note that
these are the
categories
recommended by
Stonewall ‘a leading
organisation working
Bisexual
Gay man
Gay woman/lesbian
Heterosexual/straight
Other
Prefer not to say
[
[
[
[
[
[
]
]
]
]
]
]
]
]
]
]
]
]
for equality and justice
for lesbians, gay men
and bisexuals.’)
Ethnic Category
Please tick the box
that best describes
your ethnic origin –
UK citizens can
belong to any of these
categories – this
question does not
relate to nationality.
These are the
categories that will be
used in the official
Northern Ireland
Census of 2011)
White
British or Irish
[ ]
Irish Traveller
[ ]
Any other white background
[ ]
Please specify
__________________
Other
[ ]
Chinese
[ ]
Indian
[ ]
Pakistani
[ ]
Bangladeshi
[ ]
Black Caribbean
[ ]
Black African
[ ]
Black other
3
Mixed Ethnic Group, please write in
[ ]
__________________
Any other, please write in
[ ]
__________________
Prefer not to say
[ ]
Nationality
Please write in your nationality
----------------
Caring responsibilities
Do you have caring responsibilities that exceed twenty hours a week? If yes, please tick all that
applies.
Children (under 18)
[ ]
Disabled children
[ ]
Disabled adult (18 and over)
[ ]
Elderly (65 and over)
[ ]
Other
[ ]
Marital / Civil Partnership Status
Married / In a Civil Partnership
Single
Other
Prefer not to say
[
[
[
[
]
]
]
]
Thank you for taking the time to complete this form.
You have helped us monitor our ongoing commitment to treating everyone fairly according to their ability, and nothing else.
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