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EQUALITY OF OPPORTUNITY MONITORING FORM

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EQUALITY OF OPPORTUNITY MONITORING FORM Powered By Docstoc
					EQUALITY OF OPPORTUNITY
MONITORING FORM

Loaf Bakery Limited is committed diversity and equality of opportunity. In order to monitor our
effectiveness in these areas, all applications are asked to complete this form. The information
is held confidentially.

Title      Given Name(s)                                Surname (Family Name)


Age:            16-19                    35-39                       55-59
                20-24                    40-44                       60-64
                25-29                    44-49                       65-69
                30-34                    50-54                       Prefer not to say

Marital Status:                     Married                          Single
                                    Separated                        Living With Partner
                                    Divorced                         Widowed
                                    Prefer not to say
It is unlawful to discriminate against married persons in employment under the Sex
Discrimination Act 1975. To ensure that we are not in breach of this Act we must collect and
analyse data on marital status.

Ethnic Origin: Which one of the following groups do you feel most adequately describes
your ethnic origin?
     White British                                   Asian or Asian British – Bangladeshi
     White Irish                                     Other Asian Background (Please State)
     Other White Background (Please State)           Black or Black British – Caribbean
     Mixed – White and Black Caribbean               Black or black British – African
     Mixed – White and Black African                 Other Black Background (Please State)
     Mixed – White and Asian                        Chinese
     Mixed – Other Background (Please State)         Other Ethnic Background (Please State)
     Asian or Asian British – Indian                 Unknown
     Asian or Asian British – Pakistani              Prefer not to say
If you have selected “Other”, please state your ethnic origin:



Sexual Orientation:                 Bisexual                          Other
                                    Heterosexual                      Prefer not to say
                                    Homosexual

Religious beliefs: To which of the following religions, bodies or belief systems, if any, do
you belong or affiliate with?
    Christian                                        Sikh
    Buddhist                                         I have no religious beliefs
    Hindu                                            Other (please state)
    Jewish
    Muslim                                           Prefer not to say
Disability: Please refer to the information below before answering this question.
(The Disability Discrimination Act (1995) defines a disability as a physical or mental
impairment, which has a substantial and long-term (more than 12 months) adverse effect on a
person’s ability to carry out normal day to day activities).
In order to ensure that disabled people compete fairly for jobs at the Institute, it would be
helpful if you could answer the following questions:

Do you consider yourself to be disabled / have a               Yes
disability as defined above, or if you do not consider
yourself to be disabled, do you have any long-term             No
health related condition that impacts upon your ability
to carry out normal day-to-day activities?                     Prefer not to say

If yes, please tick which category you think best describes your disability.

   Dyslexia                                        Mental health difficulties
   Blind or partially sighted                      Autistic Spectrum Disorder
   Multiple disabilities                           Personal Care support
   Deaf or hearing impairment                      An unseen disability: e.g. diabetes,
   Wheelchair User/other                           epilepsy, asthma
   mobility difficulties                           Other disabilities (please specify):

Do you have any additional support needs to enable you to attend an interview and/or if
appointed? If so, please give details:




This information is used for monitoring our equality of opportunity and diversity policies. As
such, summary information taken from this from may be retained indefinitely by Loaf Bakery
Limited. The retained information is non-identifiable, and this form, which identifies you, will
be destroyed six months from the date on which it was received, the date of your interview or
the date of termination of your employment, whichever is the later.

				
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