EQUALITY OF OPPORTUNITY MONITORING FORM
Please note that this form will only be used for monitoring purposes and will be treated as
confidential by the Clerk to the Corporation.
Equality of Opportunity
Forename
Surname
Gender
Date of Birth
Nationality
Ethnic Origin
Mixed - White and Black Caribbean
Asian or Asian British - Indian
Mixed - White and Black African
Asian or Asian British - Pakistani
Mixed - White and Asian
Asian or Asian British - Bangladeshi
Other Mixed background
Other Asian background
White
Black or Black British - Caribbean
Gypsy or Traveller
Black or Black British - African
Arab
Other Black background
Chinese
Prefer not to say
Other ethnic background
Sexual Orientation
Monitoring sexual orientation will help us to identify, tackle and prevent discrimination against lesbian,
gay and bisexual people.
How would you describe your sexual orientation?
Bisexual
Heterosexual / straight
Gay man
Other
Gay woman / lesbian
Prefer not to say
Religion or Belief
Monitoring religion or belief will help us to identify, tackle and prevent discrimination on the grounds of
religion or belief.
Do you regard yourself as belonging to any particular religion or belief system?
Buddhist
Sikh
Christian
Spiritual
Hindu
Other
Jewish
No religion
Muslim
Prefer not to say
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Disability
Do you have a disability as defined by the Equality Act 2010?
Yes
No
Do not wish to declare
If you have answered yes above, please give details:
Specific learning disability (eg dyslexia, dyspraxia)
General learning disability (eg Down’s syndrome)
Cognitive impairment (eg autistic spectrum disorder, resulting from head injury)
Long-standing illness or health condition (eg cancer, HIV, diabetes, chronic heart disease)
Mental health condition (eg depression, schizophrenia)
Physical impairment or mobility issues (eg a wheelchair user, difficulty using chair arms)
Deaf or serious hearing impairment
Blind or serious visual impairment
Other type of disability*
Multiple disabilities*
*If other type of disability or multiple disabilities, please give details:
Do you require any assistance to enable you to participate in an interview?
Yes
No
If yes, please give details of any assistance you may require for the interview:
Please use the space below to give any further information that you may wish to provide:
Criminal Records Disclosure
Rehabilitation of Offenders Act 1974
Have you any criminal convictions?
Yes
No
If yes, please provide brief details of the offence and the date of conviction. At interview, or on a
separate occasion, an open discussion will take place on the subject of any offences or other matter that
might be relevant to the position.
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Permission to Work
If you are not a citizen of the UK, European Community or European Economic Area, you may require a
Certificate of Sponsorship. If you are a citizen of Romania or Bulgaria you may require a Work Permit;
citizens of certain other EEA countries must register under the Workers Registration Scheme.
Staffordshire University may make an application for a Certificate of Sponsorship or Work Permit for
you, depending upon the post for which you are applying. If you are subject to Workers Registration you
must do this yourself. For further information regarding your right to work in the UK, please refer to the
UK Border Agency website http://ukba.homeoffice.gov.uk/workingintheuk/
Do you need permission to work in the UK?
Yes
No
If no, please indicate how you are eligible to work:
UK, EC or EEA national
Work Permit holder
Highly Skilled Migrant
Working Holiday Maker
Indefinite leave to remain
Other – please specify:
Student
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Recruitment Source
Where did you learn of this vacancy?
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