January 2015
Dear Applicant
PERSONAL DETAILS
As you may know, the Northern Ireland Act 1998 places duties on public authorities, including
Northern Ireland Screen, to have due regard to the need to promote equality of opportunity:
between persons of different religious belief, political opinion, racial group, age,
marital status or sexual orientation;

between men and women;

between persons with a disability and those without; and

between persons with dependants and those without.
These are generally referred to as the Section 75 categories.
Northern Ireland Screen has published an Equality Scheme (which can be accessed on our
website) which sets out how we will meet the statutory equality duties. One of the key
commitments in the Scheme is to monitor the impact on equality of opportunity of all our
policies, including our Recruitment Policy. We have therefore adopted the attached monitoring
questionnaire and we would be most grateful if you would complete it
We will ensure that all of the information gathered from this questionnaire will be treated with the
utmost confidentiality. The information you provide will be managed so as to fully protect
your confidentiality. No individual will ever be separately identified, nor will the information be
released to anyone in a way that would allow any individual to be identified.
The completion of the questionnaire is, of course, entirely voluntary and will have no
implications whatsoever for any future relationship between yourself and Northern Ireland
Screen. If you choose to complete the questionnaire, it would be helpful if you would return it in
the envelope provided with your application as soon as possible.
If you have any queries, please do not hesitate to contact us.
Northern Ireland Screen
Equal Opportunities Monitoring Form
1.
Age
What is your date of birth?
Day
Month
Year
2.
Gender
What is your sex? (Please tick one box).
Male
Female
3.
Marital status
What is your marital or civil partnership status? (Please tick one
box).
Single, that is, never married or in a civil partnership
Married
Separated but still legally married
Divorced
Widowed
In a civil partnership
Separated, but still legally in a civil partnership
Formerly in a civil partnership which is now legally dissolved
Surviving partner from a civil partnership
4.
Disability
(a) Do you have any long-standing illness, disability or infirmity?
By long-standing we mean anything that has troubled you over a period of time or that is
likely to affect you over a period of time? (Please tick either ‘yes’ or ‘no’)
Yes – please go to parts (b) (c) and (d)
No – please go to Question 5
(b) Does this illness or disability limit your activities in any way? (Please tick either ‘yes’
or ‘no’)
Yes
No
(c)
Please state the type of impairment which applies to you. People may experience
more than one type of impairment, in which case you may indicate more than one. If
none of the categories apply, please tick ‘Other’ and specify the type of impairment.
Physical impairment, such as difficulty using your arms or mobility
issues which mean using a wheelchair or crutches
Sensory impairment, such as being blind / having a serious visual
impairment or being deaf / having a serious hearing impairment
Mental health condition, such as depression or schizophrenia
Learning disability/difficulty, (such as Down’s syndrome or dyslexia) or
cognitive impairment (such as autistic spectrum disorder)
Long-standing illness or health condition such as cancer, HIV,
diabetes, chronic heart disease, or epilepsy
Other, please specify below
(d)
It can help us to ensure effective involvement of everyone if we can identify
anything that poses a barrier to your full participation. What are the biggest barriers for
you in doing what you want to do in this organisation? Tick any that apply.
Access to buildings, streets, and transport vehicles
Written information or communication
Verbal or audible information/communication
People’s attitudes to you because of your impairment, medical
condition or disability
Lack of reasonable adjustments
Policies or procedures such as the fire evacuation procedure
Other, please specify below
5.
Dependants
Do you have personal responsibility for the care of …. ? (Tick each
box that applies to your circumstances).
A child or children
A disabled person of any age
A dependant older person
None of the above
6.
Ethnic group
To which of these ethnic groups do you consider you belong?
(Please select the option that is most appropriate for you).
White
Chinese
Irish Traveller
Indian
Pakistani
Bangladeshi
Black Caribbean
Black African
Black other
Mixed ethnic group, please specify below
Any other ethnic group, please specify below
7.
Country of birth
What is your country of birth? Please enter the present name of
the country.
8.
Community background
Regardless of whether we practice religion, most of us in Northern Ireland are seen as
either Catholic or Protestant. We are therefore asking you to indicate your community
background by ticking the appropriate box below.
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 Roman Catholic
community
9.
Sexual orientation
My sexual orientation is towards someone (please tick one box):
Of the same sex (this covers gay men & lesbians)
A different sex (this covers heterosexual men & women)
Of the same sex and of the opposite sex (this covers bisexual men &
women)