Advocate Equal Opportunities Form

Equal Opportunities Form

In order to help us monitor the effectiveness of our equal opportunities policy, we ask all applicants to provide the information indicated below. This information will only be used for monitoring and statistical purposes.

Question Title

* 1. Ethnic Origin: How would you describe your ethnic origin?

White: English

White: Scottish

White: Welsh

White: Northern Irish

White: Irish

Black: Caribbean

Black: African

Asian: Indian

Asian: Pakistani

Asian: Bangladeshi

Asian: Chinese

Mixed Race: White & Black Caribbean

Mixed Race: White & Black African

Mixed Race: White & Asian

Would prefer not to indicate

Any other ethnic background, please describe:

Question Title

* 2. Age: What is your date of birth?

Please leave this section blank if you would prefer not to indicate.

Date / Time

Date

Question Title

* 3. Disability: Do you consider yourself to have a disability?

Yes

Would prefer not to indicate

Question Title

* 4. Disability: If you answered yes to question 3, please tick any of the list below which apply.

Dyslexic

Blind/ partially blind

Deaf/hearing impairment

Wheelchair user/ mobility difficulties

Need personal care

Mental health difficulties

Unseen disability (e.g. asthma, diabetes, epilepsy)

Multiple difficulties

Would prefer not to indicate

Other (please specify):

Advocate Equal Opportunities Form

Equal Opportunities Form

Question Title

* 1. Ethnic Origin: How would you describe your ethnic origin?

Question Title

* 2. Age: What is your date of birth?Please leave this section blank if you would prefer not to indicate.

Question Title

* 3. Disability: Do you consider yourself to have a disability?

Question Title

* 4. Disability: If you answered yes to question 3, please tick any of the list below which apply.

* 2. Age: What is your date of birth?

Please leave this section blank if you would prefer not to indicate.