EQUAL OPPORTUNITIES
RECRUITMENT MONITORING FORM
It is the policy of Middlesbrough Council to provide equal employment opportunities and consideration will be given to
all suitably experienced and qualified applicants irrespective of disability, gender, race, religion or belief, age, sexual
orientation, marital or civil partnership status.
In order to help us to monitor this policy, please complete the details below.
The information you provide will be used solely for statistical analysis and will be treated as strictly confidential.
Thank you for your assistance.
Please print legibly, using capital letters or numeric characters, as this application will be scanned.
Job Reference Number
Service Area / Department
Job Title
Grade
Date of Birth
Please tick the appropriate boxes: I AM:
Male
Female
Do you consider yourself to be a person with a disability as described by the Equality Act 2010?
Yes
No
My origin is: White:
Mixed:
Asian or Asian British:
British
White & Black
Caribbean
Indian
Irish
White & Black African
Bangladeshi
White & Asian
Any other White background, please
write below
Any other mixed background, please
write below
Black or Black British:
Other ethnic group:
Caribbean
Gypsy/Traveller
African
Chinese
Any other Black background, please
write below
Pakistani
Any other Asian background, please
write below
Prefer not to say
Any other background, please write
below
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Sexual Orientation
Relationship Status
Divorced
Bisexual
Religion or Belief
Buddhist
Christian Faith
Dissolved civil partnership
Gay
Married
Lesbian
Hinduism
Judaism
Islam
In a civil partnership
Heterosexual or Straight
Single
Prefer not to say
Sikhism
Humanism
Non-religious belief
No religion
Widow / Widower
Prefer not to say
Prefer not to say
Other
A carer spends a significant amount of their life providing unpaid support to family or friends. This could be caring for a relative,
partner or friends who are ill, frail, disabled or has a health or substance misuse problem. This should not be confused with careworker or care assistant, who receive payment for looking after someone. Are you responsible for caring without payment, for
anyone (not including parenting)? If so please tell us who you care for:
I am not responsible for caring for anyone
I care for a child / children
I care for another relative
I care for someone else
Where did you see this job advertised (Please tick box)
Blue Job Bulletin
Northern Echo
Evening Gazette
MC Web Site
Jobs North East
Mgrid Web Site
Lotus Notes
Bulletin Board
Job Centre
Herald & Post
Job Centre Website
Professional
Journal
Employer
Website
National Paper
(Please write in)
Recruitment Fair
(Please write in which fair)
northeastjobs.org
Other (Please write in)
July 2012
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