Equalities & Diversity Monitoring Questionnaire
Strictly Confidential
Monitoring the diversity of our applicants and staff is an essential part of Age UK Dudley’s
commitment to Equalities and Diversity. Please complete this form and return it with your
application form. It is entirely confidential and will not be made available to those involved in
short listing or the selection process, or for any purpose other than monitoring and statistical
reporting.
1. Age
/
Date of Birth
/
2. Gender
Male
Female
Prefer not to say
Disability
A disability is a physical or mental impairment which has a substantial long-term adverse effect
on your ability to carry out normal day-to-day activities.
Do you have any disabilities that affect you on a day to day or occasional basis?
Yes
No
Prefer not to say
3. Ethnicity
These ethnic classifications are the ones recommended by the Equality & Human Rights
Commission (EHRC) and used in the 2011 Census. Please select one box which best describes
your ethnicity. If you wish to classify yourself in some other way, please use the additional
space provided.
White
British
English
Scottish
Irish
Northern Irish
Gypsy or traveler
Welsh
Any other please state ________________________________________________
Asian
Indian
Pakistani
British
English
Bangladeshi
Chinese
Any other please state ________________________________________________
Black
African
Caribbean
British
English
Any other please state ________________________________________________
Mixed or multiple ethnic origin
White and Black Caribbean
White and Black African
White and Asian
Any other please state ________________________________________________
Any other ethnic origin
Arab
Any other please state ________________________________________________
4. Sexual Orientation
To help Age UK Dudley combat discrimination against, and to promote equality for lesbians, gay
men and women and bisexuals, it is important that we attract people of all sexual orientations.
Please select the option which best describes your sexuality:
Gay woman / Lesbian
Heterosexual
Gay man / homosexual
Bi-sexual
Prefer not to say
5. Religion & Belief
To help Age UK combat discrimination against, and to promote equality for people on the
grounds of their religion or belief, it is important that we attract people from diverse religious
groups.Please select the option which best describes your religion or belief:
Christianity
Islam
Buddhism
Sikhism
Hinduism
Judaism
Atheism
Rastafarianism
No religion or belief
Any other religious affiliation or belief
Prefer not to say
How did you find out about Age UK Dudley?
Press Article
Internet
Press Advertisement
Volunteer Bureau
Age UK Dudley Website
Poster
Leaflet
Friend or Colleague
Other – Please State
This information will be used solely by the HR Department for monitoring purposes and will be
treated as confidential. Thank you for your Co-operation 13.01.14