Application Insert 3
Queen’s University of Belfast
Doctorate in Clinical Psychology
EQUAL OPPORTUNITIES MONITORING FORM – 2016
Insert 2 monitors applications for the Northern Ireland Health and Social Services. This insert monitors applications
on behalf of the D.Clin.Psych. course at Queens. The information will be treated as strictly confidential. The form will
be separated from your application and used for statistical purposes only after selection has taken place. For each
item, please give the code for the category into which you fall.
1. GENDER
Female
Male
=1
=2
2. AGE
<25
25-34
35-44
>45
=1
=2
=3
=4
3. MARITAL STATUS
4.
Single
Married, civil partnership
or cohabiting
Widowed
Divorced/ separated
=1
=2
=3
=4
RELIGIOUS AFFILIATION
I am a member of the Protestant community
I am a member of the Roman Catholic community
I am a member of neither the Protestant nor the
Roman Catholic community.
5. DO YOU HAVE DEPENDENTS?
Yes
=1
=1
=2
=3
No = 2
6. PLEASE INDICATE YOUR ETHNIC ORIGIN (origin of recent forebears)
White
Black - Caribbean
Black- African
Black - Other
Indian
=1
=2
=3
=4
=5
Pakistani
Bangladeshi
Chinese
Irish Traveller
Other
=6
=7
=8
=9
= 10
If other, please specify ..........................………
7. COUNTRY OF ORIGIN
Northern Ireland = 1
Scotland or Wales) = 3
Republic of Ireland = 2
Other UK (England,
Other EU = 4
Other Non-EU = 5
8. COUNTRY OF RESIDENCE
Northern Ireland = 1
Scotland or Wales) = 3
Republic of Ireland = 2
Other UK (England,
Other EU = 4
Other Non-EU = 5
9. My sexual orientation is towards:
The Opposite Sex = 1
The Same Sex = 2
Both Same and Opposite Sex = 3
Would rather not say = 4
10. In line the Disability Discrimination Act 1995, a disability is defined as:
“a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry
out normal day to day activities”
Do you consider yourself to have a disability?
1 = Yes 2 =No
If YES, please circle one or more below as appropriate
1 You have a specific learning difficulty (e.g. dyslexia)
2 You are blind or partially sighted
3 You have hearing difficulties
4 You use a wheelchair or have mobility difficulties
5 You have mental health difficulties
6 You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
7 You have a disability which cannot be seen (e.g. epilepsy, diabetes, heart condition)
8 Other (please specify)………