Recruitment monitoring form ALT186 – These characteristics have been identified by The Riverside Group as differences that are most likely to result in people being treated unfairly or to require different consideration in how we deliver our services. We understand that the options set out in this form may not cover the diverse range of characteristics with which someone might identify and therefore wherever possible an option is provided to allow self-description. DATE OF BIRTH: HOW WOULD YOU DESCRIBE YOUR GENDER IDENTITY? Please tick or describe as appropriate. Male Female Non-binary* Prefer not to say *do not identify as male or female Do you consider yourself to be a transgender person? Please tick as appropriate. Yes No Prefer not to say DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY? (a disability is identified as having a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities) Please tick as appropriate. Yes No Prefer not to say If you ticked please state whether your disability relates to one of the following: ‘yes’, Wheelchair user Visual Impairment Mental health disability Mobility difficulties Speech Impairment Prefer not to say Learning Hearing Impairment disability/difficulties Self-description:…………………………………………………………………………………… HOW WOULD YOU DESCRIBE YOUR SEXUAL ORIENTATION? Please tick or describe as appropriate. Heterosexual Gay Woman Prefer not to say Bisexual Gay Man Self-description:……………………………………………………………………………… HOW WOULD YOU DESCRIBE YOUR RELIGION OR BELIEF? Please tick or describe as appropriate. Christian (all denominations) Hindu Buddhist Jewish Sikh Muslim None Prefer not to say Self-description:…………………………………………………………………………………….
Recruitment monitoring form – ALT186 These characteristics have been identified by The Riverside Group as differences that are most likely to result in people being treated unfairly or to require different consideration in how we deliver our services. We understand that the options set out in this form may not cover the diverse range of characteristics with which someone might identify and therefore wherever possible an option is provided to allow self-description. DATE OF BIRTH: HOW WOULD YOU DESCRIBE YOUR GENDER IDENTITY? Please tick or describe as appropriate. Male Female Non-binary* Prefer not to say *do not identify as male or female Do you consider yourself to be a transgender person? Please tick as appropriate. Yes No Prefer not to say DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY? (a disability is identified as having a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities) Please tick as appropriate. Yes No Prefer not to say If you ticked ‘yes’, please state whether your disability relates to one of the following: Wheelchair user Visual Impairment Mental health disability Mobility difficulties Speech Impairment Prefer not to say Learning disability/difficulties Hearing Impairment Self-description:…………………………………………………………………………………… HOW WOULD YOU DESCRIBE YOUR SEXUAL ORIENTATION? Please tick or describe as appropriate. Heterosexual Gay Woman Prefer not to say Bisexual Gay Man Self-description:……………………………………………………………………………… HOW WOULD YOU DESCRIBE YOUR RELIGION OR BELIEF? Please tick or describe as appropriate. Christian (all denominations) Hindu Buddhist Jewish Sikh Muslim None Prefer not to say Self-description:…………………………………………………………………………………….
Recruitment-monitoring-form-ALT186.docx