Script Starter 2022 Equal Opportunities Form

EQUAL OPPORTUNITIES MONITORING FORM

Script Starter encourages applications from and gives equal access to all sections of the community. To help us monitor this, please provide us with the following information. (The information you provide in this form will be treated as strictly confidential and will be used for monitoring purposes only.)

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* 1. Gender

Female

Male

Gender Non-Binary

Please tick if your gender is different than the sex you were assigned at birth

Prefer not to say

Prefer to self-identify as:

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* 2. Age group:

18-29

30-39

40-49

50-59

60+

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* 3. Ethnic Origin

Asian or Asian British – Indian

Asian or Asian British – Pakistani

Asian or Asian British – Bangladeshi

Asian or Asian British – Chinese

Asian or Asian British - Other

Black or Black British – Caribbean

Black or Black British – African

Black or Black British – Other

Mixed – White and Black Caribbean

Mixed – White and Black African

Mixed – White and Asian

Mixed – Other

White – Scottish

White - English/Welsh/Northern Irish/British

White – Irish

White – Other

Arab

Other (please specify)

Prefer not to say

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* 4. Do you consider yourself to be a disabled person?* Disability, as defined by the Disability Discrimination Act, covers many people who may not usually have considered themselves disabled. It covers physical or mental impairments with long term, substantial effects on ability to perform day-to-day activities.

Yes

Prefer not to say

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* 5. Nature of disability (please tick all that apply):

Deaf or hearing impaired

Blind or visually impaired

Musco-skeletal (co-ordination/dexterity/mobility)

Mental health (including serious depression)

Learning disabilities (includes dyslexia)

Long-term illness or debilitating disease

No disability

Prefer not to say

Other

Other (please specify)

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* 6. In which of the following Nations or English regions do you live?

Wales

Scotland

Northern Ireland

London

South East

South West

West Midlands

East Midlands

East of England

North East

Yorkshire and the Humber

North West

Outside the UK

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* 7. Which of the following options best describes how you think of yourself?

Heterosexual or Straight

Gay Man

Gay Woman / Lesbian

Bisexual

Prefer not to say

Other (please specify)