Royal School for the Deaf Derby
Confidential Diversity Monitoring Form
Royal School for the Deaf Derby wants to live up to the standards set out in it’s Equality and Diversity policies,
procedures and practice and to meet its legal obligations in respect of age, disability, gender, race or ethnic
origin, religion or belief and sexual orientation. We need your help and co-operation to do this. By providing
this information you are helping us to ensure our policies and practices are non-discriminatory and wherever
possible reflect the diverse population of our School and wider communities.
Please email your questionnaire back to Helen Radford at helen.radford@rsdd.org.uk or send it marked “Strictly
Confidential’ to Helen Radford, Human Resources Manager, Royal School for the Deaf Derby Trust Company,
Ashbourne Road, Derby DE22 3BH
Full Name
Role applied for:
1. Please select your age band
16 - 21
22 - 30
31 - 40
41 - 50
51 - 59
60-65
Over 65
Prefer not to say
2. Do you consider yourself to have a disability or health condition?
Yes
No
Prefer not to say
What is the impact of your disability or health condition on your ability to give your best at work?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. What is your ethnic group?
A. Asian or Asian British
B. Black or Black British
Bangladeshi
Indian
Pakistani
Prefer not to say
African
Caribbean
Prefer not to say
Any other Asian background, please write in:
_______________________________________________
Any other Black background, please write in:
_______________________________________________
C. Chinese
D. Mixed Heritage
Chinese
Prefer not to say
White and Asian
White and Black African
White and Black Caribbean
Prefer not to say
Any other Chinese background, please write in:
_______________________________________________
Any other Mixed background, please write in:
_______________________________________________
E. White
4. What is your religion or belief
Buddhist
British
English
Irish
Scottish
Welsh
Prefer not to say
Any other White background, please write in:
_______________________________________________
F. I do not wish to disclose my ethnic group
Muslim
Christian
No religion or belief
Hindu
Sikh
Jewish
Prefer not to say
Royal School for the Deaf Derby
Confidential Diversity Monitoring Form
4. What is your sexual orientation
Bisexual (attracted to people of the same and the
opposite sex)
Gay (man attracted to other men)
5. Please describe your gender
Male
Heterosexual (attracted to people of the opposite sex)
Other
Female
Prefer not to say
Lesbian (woman attracted to other women)
Prefer not to say
Do you identify as transgender (an individual who
wants to change their gender to the opposite of that
they were assigned at birth)?
Yes
Other, please write in:
_______________________________________________
No
Prefer not to say