Output Name:
Diversity Declaration form – England, Scotland and Wales
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;
Baha'i faith
Jainism
Paganism
Rastafarianism
Zoroastrians
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 health-related
questions before you have offered the individual a job. (See ACAS Guide „The Equality Act –
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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
Disability Status
Do you consider yourself to have a disability?
Yes
[ ]
[ ]
FeFemale
No
[ ]
[ ]
PPrefer not to say [ ]
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).
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• 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
Religion
I would describe my religion or belief as:
(Please note that these
are categories that will
be used in the 2011
UK Census form)
Sexual Orientation
(Please note that these
are the categories
recommended by
Stonewall, ‘a leading
organisation working for
equality and justice for
lesbians, gay men and
bisexuals.‟)
[ ]
No Religion (including Humanist, Atheist or Agnostic)
Buddhism
Christianity - (including Church of England, Catholic,
Protestant and all other Christian denominations)
Hinduism
Islam
Judaism
Sikhism
Any other religion or belief, please write in
………………...........................................
Prefer not to say
[ ]
[ ]
[ ]
[
[
[
[
[
]
]
]
]
]
[ ]
What is your Sexual Orientation:
Bisexual
Gay man
Gay woman/lesbian
Heterosexual/straight
Other
Prefer not to say
[
[
[
[
[
[
]
]
]
]
]
]
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 UK Census of
2011)
White
English / Welsh / Scottish / Northern Irish / British
[ ]
Irish
[ ]
Gypsy or Irish Traveller
Any other white background
[ ]
[ ]
Please write in
___________________
2
Mixed / multiple ethnic groups
White and Black Caribbean
[ ]
White and Black African
[ ]
White and Asian
[ ]
Any other mixed/ multiple ethnic background
[ ]
Please write in
___________________
Asian / Asian British
Indian
[ ]
Pakistani
[ ]
Bangladeshi
[ ]
Chinese
[ ]
Any other Asian background
[ ]
Please write in
___________________
African / Caribbean / Black / Black British
Caribbean
[ ]
African
[ ]
Any other African / Caribbean / Black background
[ ]
Please write in
___________________
Other ethnic group
Nationality
Arab
[ ]
Other
[ ]
Please specify
___________________
Prefer not to say
[ ]
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
[ ]
3
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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