Equal Opportunities Monitoring Form
Data Protection Act 1998: Equal opportunities information will be used only for monitoring the performance of the organisation and not for selection purposes.

1. Please look at the descriptions of race and ethnic origin listed
below and circle the one that most accurately describes you.

Black or Black British			Asian or Asian British
Caribbean					Indian
African						Pakistani
Other	(please state)				Bangladeshi 
Other (please state)


Mixed						White
White & Black Caribbean			British 
White & Black African			Irish
White & Asian 				Other (please state)
Other (please state)


Chinese 

Other Ethnic 
Group (please state)


2.Which age group do you belong to?

Under 20
20 - 29
30 - 39
40 - 49
50 - 59
60 and above


3. Gender:

Male		Female	Transgender



3. Do you have a disability?

The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and long term (for more than 12 months) adverse effect on a person's ability to do normal daily activities. You may still be considered to have a disability if you are not currently adversely affected but the impairment is likely to recur.

No  	Yes